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Text-Book of Hygiene 

A COMPREHENSIVE TREATISE 

ON THE 

Principles and Practice of Preventive Medicine 

FROM AN AMERICAN STAND-POINT. 



GEORGE H. ROME, M.D., 

PROFESSOR OF THERAPEUTICS, HYGIENE, AND MENTAL DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 

BALTIMORE ; SUPERINTENDENT OF THE MARYLAND HOSPITAL FOR THE INSANE ; MEMBER OF THE 

AMERICAN PUBLIC HEALTH ASSOCIATION; FOREIGN ASSOCIATE OF THE SOCIETE 

FRANCAISE D'HYGIENE, ETC. 



THIRD EUDITIOKT 

Thoroughly Revised and Largely Rewritten, with Many 
Illustrations and Valuable Tables. 




"7 



i ■ -• 



PHILADELPHIA : 

THE F. A. DAVIS COMPANY, PUBLISHERS. 

LONDON : 

F. J. REBMAN. 

1894. 



/V, 



A 



COPYRIGHT, 1891, 

BY 

F. A. DAVIS. 
COPYRIGHT, 1894, 

BY 

THE F. A. DAVIS COMPANY. 
[Registered at Stationers' Hall, London, Eng.] 



PhiLd-lf-hi* ! 
The Medical Bulletin Printing-Honae, 
1916 Cherry 8treet. 



TO 



HENRY INGERSOLL BOWDITCH, A.M., M.D., 

Tke Pioneer 



Oi THE FIELD OF 



E=i?.Ei\7-E:isrTi^7-EL ixtehdigii^e: 



AMERICA. 



(iii) 



PREFACE TO THE FIRST EDITION. 



The aim of the author in writing this hook has heen to 
place in the hands of the American student, practitioner. 
and sanitary officer, a trustworthy guide to the principles 
and practice of preventive medicine. 

He has endeavored to gather within its covers the essen- 
tial facts upon which the art of preserving health is hased, 
and to present these to the reader in clear and easily 
understood language. 

The author cannot flatter himself that much in the 
volume is new. He hopes nothing in it is untrue. 



00 



PREFACE TO THE THIRD EDITION. 



In this edition every chapter has been subjected to a careful 
revision, and the advances in sanitary science and practice have 
been incorporated. 

Recent legislation in the United States and Canada has 
almost revolutionized quarantine practice. Surgeon-General 
Walter Wyman, and Dr. H. D. Geddings, of the United 
States Marine-Hospital Service, have, at the request of the 
author, entirely rewritten the chapter upon Quarantine, and 
it will be found to represent fully the modern principles and 
practice of maritime sanitation. 

Medical Director Albert L. Gihon, United States Navy, has 
again thoroughly revised the chapter on Marine Hygiene. 

With the view of making the book still more useful to 
teachers, students, and sanitary officers than heretofore, an ana- 
lytical set of questions has been appended to each chapter, and 
a separate section has been added on methods of examination 
of air, water, and food. For these additions the author is 
indebted to Professor Seneca Egbert, of Philadelphia. Dr. 
Egbert has also carefully revised the chapter on Vital Statistics. 

The author desires to thank all who have assisted him in 
the work, and especially the sanitarians throughout the country 
who have been helpful in the way of criticism and suggestion. 
He hopes that the new edition will merit, as well as receive, the 
approval of all students of Preventive Medicine. 



Baltimore, Md., October, 



(vii) 



CONTENTS. 



CHAPTER I. 

PAGE 

Air, . 1 

CHAPTER II. 
Water, 49 

CHAPTER III. 
Food, 8t 

CHAPTER IV. 
Soil, 131 

CHAPTER V. 

Removal of Sewage, . . . . . . . . .147 

CHAPTER VI. 
Construction of Habitations, 165 

CHAPTER TIL 

Construction of Hospitals, 195 

CHAPTER VIII. 
School Hygiene, 207 

CHAPTER IX. 
Industrial Hygiene, 223 

CHAPTER X. 
Military and Camp Hygiene, 249 

CHAPTER XL 
Marine Hygiene, 261 

CHAPTER XII. 

Prison Hygiene, 279 

(ix) 



X CONTENTS. 

CHAPTER XIII. 

PAGE 

Exercise and Training 285 

CHAPTER XIV. 
Baths and Bathing, 293 

CHAPTER XV. 
Clothing, . . . . 301 

CHAPTER XVI. 
Disposal of the Dead, 307 

CHAPTER XVII. 
The Germ Theory of Disease, ...!... 313 

CHAPTER XVIII. 
Contagion and Infection, 319 

CHAPTER XIX. 

History of Epidemic Diseases, 325 

CHAPTER XX. 

Antiseptics, Disinfectants, and Deodorants, .... 387 

CHAPTER XXI. 
Vital Statistics, 401 

CHAPTER XXII. 
The Examination of Air, Water, and Food, .... 413 

CHAPTER XXIII. 
Quarantine, 441 

Index, 547 



Text-Book of Hygiene, 



CHAPTER I. 



Air. 

Exact investigation into the influence of the atmosphere 
upon health is yet in its infancy. Enough has been learned, 
however, to show that changes in the composition of the air, in 
its density, its temperature, its humidity, its rate and direction 
of motion, and possibly its electrical or magnetic conditions, 
influence in various ways the health of the individual. It is 
only very recently that any scientific attempts have been made 
to trace the bearing of atmospheric changes upon health. The 
observations already recorded indicate that a thorough study of 
meteorological phenomena in connection with the origin and 
progress of certain diseases is a promising field of labor for the 
educated sanitarian. The meteorological observations which 
have been gathered by the United States Signal Service during 
the past twenty- three years, together with elaborate studies 
made by the meteorologists and climatologists of other countries, 
already form such a large and tolerably complete and well- 
arranged body of facts, that reasonably accurate deductions can 
even now be made. Heretofore, in studying the sanitary rela- 
tions of the atmosphere, both in this country and abroad, the 
attention of observers has been riveted almost exclusively upon 
the changes in its composition occurring within certain limited 
areas. It is, perhaps, equally important to study this universally 
diffused and necessary condition of vital activity in its broader 
and more general relations. It will be shown, in the course of 
the present work, that the meteorological features of countries, 

(i) 



2 TEXT-BOOK OF HYGIENE. 

or of seasons, or even the daily atmospheric changes, exercise an 
important influence upon life and health. In order to fully 
appreciate these relations it will be necessary to first give a brief 
summary of the facts and laws of meteorology. 

THE COMPOSITION AND PHYSICAL CONDITIONS OF THE ATMOSPHERE. 

Atmospheric air is a mixture of four-fifths of nitrogen and 
one-fifth of oxygen; more accurately, 79.00 of the former to 
20.96 of the latter. In addition, there is constantly present a 
modicum of carbon dioxide, usually a little over .03 per cent. 
(3 to 4 parts in 10,000), traces of ammonia and nitric acid, and 
a variable proportion of vapor of water. 

These proportions are maintained, with but very little 
change, at different heights. At first thought, it would seem 
that carbon dioxide, being much heavier than the other con- 
stituents of air, would accumulate in the lower regions of the 
atmosphere, and there cause an excess of this poisonous con- 
stituent, but in obedience to the law of diffusion the interming- 
ling of the component gases is perfect, and the proportion of 
carbon dioxide in the atmosphere is quite as great on mountain- 
tops as in the deepest valleys. 

The proportion of nitrogen in atmospheric air is generally 
uniform, while that of oxygen varies, depending to a great ex- 
tent upon the amount of carbon dioxide present. Hence, an 
increase in the amount of the latter constituent is usually ac- 
companied by a diminution of oxygen, inasmuch as the formation 
of carbon dioxide can only take place at the expense of oxygen. 
The reciprocal activities of animal and vegetable life are beauti- 
fully illustrated by these relations between the oxygen and 
carbon dioxide in the air. In the processes of combustion and 
oxidation, oxygen is withdrawn from the atmosphere, and com- 
bines with carbon, forming carbon dioxide. During vegetable 
growth, on the other hand, carbon dioxide is withdrawn from 
the air by the leaves of plants, and decomposed into its elements, 
carbon and oxygen. The carbon is used in building up the 



COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 3 

plant, while the liberated oxygen is restored to the atmosphere. 
The animal consumes oxygen, and gives out carbon dioxide; 
the plant resolves this compound into its constituent elements, 
and gives back the oxygen to the air again. 

Some recent experiments of Jolly have shown that on days 
of northerly winds the proportion of oxygen is higher than the 
average, while under the influence of the south wind the propor- 
tion of oxygen is deficient. The extremes in a series of 21 
observations were 21.01 and 20.53 per cent. The difference, 
.48 per cent., is too small to have any appreciable influence 
upon health. 

The atmosphere extends upward from the surface of the 
earth to an indefinite distance. The limit has been variously 
placed at from 75 kilometres to 40,000 kilometres. For all 
sanitary purposes the former may be taken as the upward limit 
of the atmosphere. In obedience to the law of gravity, this 
mass of air everywhere presses directly downward — toward the 
earth's centre — with a force equal to its weight. If a column 
of this air be balanced by a column or mass of any other matter — 
the columns being of the same diameter — we have a relative 
measure of the weight of the atmosphere. The instrument with 
which the weight or downward pressure of the air is measured 
is called a barometer. The atmosphere, at the sea-level, presses 
downward with a force equal to the pressure of a column of 
mercury 760 millimetres high. Hence, the barometric pressure 
at sea-level is said to be 760 millimetres, or 30 inches. If the 
barometer be carried to the summit of a mountain 1000 metres 
above the level of the sea, or taken to the same altitude in a 
balloon, the mercury in the barometer-tube will fall about 
90 millimetres. These 90 millimetres of the mercurial column 
represent the weight of 1000 metres of air now below the 
barometer, and consequently not measured or balanced by it. 1 

Upon ascending from the sea-level, it is found also that the 

1 The figures here given are not absolute, hut merely approximate. The limits of this 
work do not allow a full discussion of the meteorological elements modifying the pressure of 
the atmosphere at sea-level. 



4 TEXT-BOOK OF HYGIENE. 

air. being less pressed upon by that which is still above it, 
becomes more rarefied and lighter; its tension, as it is termed, 
is less. Hence, for the second 1000 metres of ascent above the 
sea, the mercury will fall a less distance in the tube, the weight 
removed not being so great as in the first 1000 metres. 

The following table shows the diminution -in atmospheric 
pressure for every 1000 metres above sea-level: — 



Height. 






Barometric Pressure. 


Sea-level, 760.0 millimetres 


1,000 metres, 


. 




. 670.4 " 


2,000 " . 


. 




591.5 " 


3,000 " . 


. 




521.0 " 


4,000 " . 


. 




460.3 " 


5,000 " . 


. 




. 406.0 " 


6,000 " . 


. 




358.2 " 


7,000 " . 






. 316.0 " 


8,000 " . 


. 




. 278.8 " 


9,000 " . 


. 




245.9 " 


10,000 " . 


. 




216.9 " 


11,000 " . 


. 




191.1 " 


12,000 " . 


. 




168.8 " 


15,000 " . 


. 




115.9 " 


20,000 " . 


• 


, 


61.9 " 



Variations in temperature and humidity of the air influence 
the tension of the atmosphere in a marked degree, and affect 
the height of the barometric column. In fact, most of the 
changes of atmospheric pressure at the surface of the earth are 
directly due to changes in temperature and humidity. Increase 
of temperature diminishes the density of the air. Hence, when 
the temperature rises the pressure decreases. 

The proportion of moisture (aqueous vapor), if increased, 
likewise en uses a diminution in pressure. It is found, for ex- 
am pie. that when the amount of aqueous vapor in the air 
increases the barometer falls. This is due to the fact that the 
specific gravity of aqueous vapor is less than that of dry air, 
being in the proportion of .623 to 1.000. Hence, as aqueous 



COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 5 

vapor is diffused through air, the latter becomes lighter, — or, in 
other words, the barometric pressure diminishes. 

The warmth of the air is primarily derived from the sun. 
On a clear day about one-fourth of the heat of the sun's rays is 
given off directly to the air during the passage of the heat- 
rays to the earth. Of the remaining three-fourths, part is re- 
flected from the earth, while the larger portion is first absorbed 
by the earth, and then given off by radiation and convection to 
the superincumbent air. 

The air is always warmer near the earth's surface on a clear, 
sun-shiny day; for, as soon as the earth gets warmer than the 
air immediately above it, the excess of heat is given off to the 
latter by convection and radiation. On ascending from the 
surface of the earth the temperature decreases, and on the 
summit of a high mountain the air is always colder than at 
its base. 

Professor Tyndall has shown that dry air absorbs less 
heat than air which is charged with vapor. For this reason 
the sun's rays strike the earth with much greater intensity 
on a very dry than on a moist day, while on the latter a larger 
proportion of the heat-rays is intercepted before they reach 
the earth. 

Recent experiments seem to show, however, that the differ- 
ence in diathermancy between dry and humid air is not so great 
as supposed by Tyndall. The depth of the air-stratum, through 
which the sun's rays pass, is of greater influence than the 
humidity. 

Air, at different temperatures, is capable of absorbing 
different amounts of aqueous vapor. Thus, air at a temperature 
of 4° will require a much smaller amount of vapor to produce 
saturation than air at a temperature of 30°. For this reason 
air which appears " damp " at the former temperature, both to 
the bodily sensations and to appropriate instruments, would be 
considered as "dry" at the latter temperature, although the 
actual amount of vapor present, or absolute humidity, is the 



{] TEXT-BOOK OF HYGIENE. 

same in both cases. 1 In meteorological observations for sanitary 
purposes, the relative humidity is the condition deserving 
especially careful study. 

It must be borne in mind that the mere statement of the 
percentage of relative humidity, without taking into account the 
temperature of the air, is of little significance. A like remark 
is justified with regard to statements of absolute humidity, when 
ii-ed to illustrate the apparent effects of atmospheric moisture 
upon life and health. 

The following table shows the absolute humidity corre- 
sponding to the same relative humidity at different tempera- 
tures. It also includes the total possible absolute humidity 
and the difference between the actual and possible humidity 
(deficiency of saturation) at the temperatures given : — 

Table II. 



Tempera- 
ture °C. 


Relative 
Humidity 

(per cent.). 


Absolute Humidity 
(grammes per 
cubic metre). 


Greatest Possible 
Absolute Humidity. 


Deficiency of 
Saturation. 


—20 

—10 



-hio 

20 
30 


60 
60 
60 
60 
60 
60 


0.638 
1.380 
2.924 
5.623 
10.298 
18.083 


1.064 
2.300 
4.874 
9.372 
17.164 
30.139 


0.426 
0.920 
1.950 
3.749 
6.866 
12.056 



In forests the relative humidity is usually higher than over 
un wooded districts, although the absolute humidity may be the 
Bame, or, perhaps, even less. The evaporation is usually much 
iter iii the open air than in forests. In closed apartments 
the evaporation may be greater or less than in the open air, de- 
pending upon the local conditions present. 

1 By "absolute humidity" is meant the total amount of vapor present in a certain mass 
r. By the term "relative humidity " meteorologists designate the proportion of vapor 
present at i <rt;.in temperatures, compared with full saturation of the air with vapor, which is 
i which la saturated, or whose relative humidity is 100 at 4°, would have 
a relative humidity of only 24, if the temperature were raised to 27°, because in the latter case 
the eapacit) of the :.ir for aqueoui vapor is Increased. Relative humidity is always designated 
in pi absolute humidity in grammes per cubic metre or grains per cubic foot. 



COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 7 

The motion of the air — wind — is caused by differences in 
pressure ; the latter being due to differences in temperature and 
humidity. A mass of air traversing a large body of water absorbs 
vapor, unless already saturated, and becomes moist ; if it pass 
over a wide tract of dry land it loses moisture and becomes dry. 
Therefore in the eastern portion of the American continent, an 
easterly or southerly wind, which comes from over large bodies 
of water, and which is usually warm, and thus capable of hold- 
ing a large quantity of water in a state of vapor, is always 
moist. On the other hand, a northerly or westerly wind, com- 
ing over a large extent of dry land, and from a colder region, is 
nearly always a dry wind. On the Pacific coast these condi- 
tions are reversed ; there a westerly wind is a moist wind, while 
an easterly wind is dry. The dreaded easterly wind of England 
is likewise a dry wind. It is probable that the direction and 
rate of motion of air-currents have considerable influence upon 
the origin or intensification of certain diseases. 

The electrical and magnetic conditions of the atmosphere 
have been as yet studied to little advantage. It is only known 
that atmospheric electricity is, in most cases, positive, and that 
its intensity increases with condensation of vapor. There seems 
to be no doubt that the varying states of atmospheric electricity 
are closely connected with evaporation and condensation. There 
is reason to believe that a fuller knowledge on these topics will 
yield most important results to the student of hygiene. 

Ozone and antozone, or hydrogen peroxide, are usually 
present in the atmosphere in varying proportions. Careful and 
extended observations have failed to show any connection be- 
tween the presence of these agents in the atmosphere and modi- 
fications of health. It is probable that the sanitary importance 
of ozone and of hydrogen peroxide have been much overrated. 
It is not known that either of these substances has any other 
function in the atmosphere than that of an oxidizing agent. 

The sanitarian should be a practical meteorologist. In 
addition to a knowledge of the principles of the science, he 



s 



TEXT-BOOK OF HYGIENE. 



should possess the skill to make accurate observations of me- 
beorological conditions, and estimate their significance. But the 
acquisition of an elaborate collection of instruments, and their 
regular observation, is too expensive and time-consuming. A 

German physicist, Lambrecht, has de- 
vised an instrument which combines in 
itself nearly all the requirements of a 
trustworthy meteorological instrument 
(Fig. 1). This instrument is called a 
polymeter, and shows, on easily-readable 
scales, the temperature, relative humid- 
ity, dew-point, absolute humidity in 
grammes per cubic metre, and vapor 
tension. 

INFLUENCE OF CHANGES OF ATMOSPHERIC 
PRESSURE ON HEALTH. 

The effects of a considerable dimi- 
nution of pressure are familiar to every 
one in the " mountain sickness " which 
attacks most persons on ascending high 
mountains. M. Bert has shown experi- 
mentally that similar effects can be 
produced in an air-tight chamber by 
diminishing the pressure. 1 The symp- 
toms produced under a pressure equiva- 
lent to an altitude of from 4000 metres 
to 5000 metres were a feeling of heavi- 
ness, nausea, ocular fatigue, rapidity 
of pulse, convulsive trembling on slight 
exertion, and a sensation of languor 

and general indifference to the surroundings of the individual. 
M. Lortet, who lias left on record his experiences in the 

higher Alp that the symptoms noticed on ascending to 

1 Popular Science Monthly, v, p. 379. 




FIG. 1. 

Lambkkciit'.s I 'oxymeter. 



INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 9 

high altitudes are: Labored respiration, increased rapidity of 
pulse, depression of temperature (as much as 4° to 7° C). The 
normal temperature was restored, however, after a brief rest. 1 
Still more severe symptoms have been noticed on ascending high 
mountains in South America and Asia. Aeronauts have lost 
consciousness, and in several instances life, on rapidly ascending 
to great altitudes. 2 According to the observations of the 
brothers Schlagintweit, distinguished explorers of the highlands 
of Asia, the effects of diminished pressure upon the human 
organism are : " Headache, difficulty of respiration, and affec- 
tions of the lungs, — the latter even proceeding so far as to 
occasion blood-spitting, — want of appetite, and even nausea, 
muscular weakness, and a general depression and lowness of 
spirits. All these symptoms, however, disappear in a healthy 
man almost simultaneously with his return to lower regions." 
A singular observation was made by these travelers on the effect 
of motion of the air upon the symptoms described. They say: 
" The effects here mentioned were not sensibly increased by 
cold, but the wind had a most decided influence for the worse 
upon the feelings When occupied with observa- 
tions, we took very little, if any, bodily exercise, sometimes for 
thirty-six hours ; it would frequently occur nevertheless, even in 
heights not reaching 17,000 feet (about 5150 metres), that an 
afternoon or evening wind would make us all so sick as to take 
away every inclination for food. No dinner was cooked; the 
next morning, when the wind had subsided, the appetite was 
better. 

" The effects of diminished pressure are considerably aggra- 
vated by fatigue. It is surprising to what degree it is possible 
for exhaustion to supervene ; even the act of speaking is felt to 
be a labor, and one gets as careless of comfort as of danger. 
Many a time our people — those who ought to have served us as 
guides — would throw themselves down upon the snow, declaring 

1 Realencyclopaedie d. ges. Heilk., v., p. 529. 

2 MM. Sivel and Croce-Spinelli, two aeronauts, lost their lives in this manner during an 
ascent from Paris, in April, 1875. 



10 TEXT-BOOK OF HYGIENE. 

they would rather die upon the spot than proceed a step 
farther." 1 

These symptoms disappear when persons are exposed to 
these conditions for a prolonged time. Thus, in the Andes 
there are places 4000 metres above sea-level which are per- 
manently inhabited ; and in the Himalayas there are villages 
at a height of over 5000 metres constantly occupied. In this 
country, Pike's Peak, 4350 metres above the sea, has been 
occupied since 1873 by observers of the signal service. The 
men seem to become acclimated, as it were, and suffer little or 
no inconvenience from the diminished pressure after a time. 

The minor disturbances of healthy function produced by 
diminished pressure (within the limits of 4000 metres altitude, 
or 460 millimetres barometric pressure) are an increase in the 
pulse and respiration rate. This is probably due to the struggle 
of the organism to take up the required quantity of oxygen 
which is reduced in proportion by the rarefaction of the air. 
For example, the proportion of oxygen at a pressure of 460 
millimetres would be equivalent to 12.6 per cent, at sea-level, 
instead of the normal 20.9 per cent. 

Paul Bert has shown by personal experiments in the 
pneumatic chamber that the increase in pulse and respiration 
rate is not due to the merely mechanical diminution of pressure, 
but to the deficiency of oxygen. Hence the physiological effects 
of high altitudes upon circulation and respiration are not purely 
physical, due to diminished pressure, but vital, and depend upon 
the change in the chemical composition of the atmosphere. 
The simple diminution of oxygen without reduction of pressure 
will produce similar though not identical effects upon the 
organism. 

Above the height of 4000 metres above sea-level (below 
460 millimetres pressure) the profounder disturbances of func- 
tion characterized as " mountain sickness " come on. Different 

1 Results of a Scientific Mission to India and High Asia. By Hermann, Adolphe, and 
Robert De Schlagintweit, vol. ii, pp. 484, 485. 



INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 11 

individuals react in different degree to the morbific influences of 
greatly diminished atmospheric pressure (and coincident reduc- 
tion of oxygen). Thus Glaisher reached an elevation of 11,000 
metres (191.1 millimetres pressure) and returned to the earth 
alive, while Croce-Spinelli and Sivel perished at the considerably 
lower elevation of 8000 metres, equivalent to a pressure of 260 
millimetres (7.2 per cent, of oxygen). 

The sanitarian is most concerned about the effects of press- 
ure of the atmosphere from 760 millimetres down to 460 milli- 
metres (or up to an altitude of 4000 metres above sea-level). 
The climatotherapy of various diseases requires that the effects 
of variations of pressure between these limits should be carefully 
studied. The observations of Mermod and Jourdanet 1 have 
illustrated the common physiological effects of these circum- 
scribed changes, while the experiences of therapeutists have 
established the fact very clearly that many cases of phthisis 
improve markedly in a rarefied atmosphere. Other observers 
have also shown that the effects of diminished pressure are not 
always beneficial, and Dr. Loomis has warned against the send- 
ing of patients with heart disease to high altitudes. Whether 
the lethal effects that have been recorded in such cases are due 
to the increased activity of the heart and heightened blood- 
pressure from deficient oxygen, or as suggested by Dr. F. Don- 
aldson, Jr., to dilatation of the heart- walls from diminution of 
external pressure, is as yet unsettled. 2 

It is probable that the diurnal or accidental 3 oscillations of 
barometric pressure at sea-level have no appreciable influence 
upon the organism. The statement is occasionally met that 
patients subjected to grave surgical operations oftener do badly 
during low atmospheric pressure, and some surgeons never 

1 Jourdanet states that while the French and Belgian soldiers in Mexico had an accel- 
erated pulse, the natives had a normal pulse. In Merniod's observations the average frequency 
of the pulse at St. Croix (1106 metres above sea-level) was nearly four beats greater than at Strass- 
burgh (142 metres). The condition of the natives at the high settlements of the Andes and Hima- 
layas has not yet been investigated with exactitude. 

2 American Climatological Association, 1887. 

3 Meaning the oscillation produced by storm waves. 



12 TEXT-BOOK OF HYGIENE. 

operate when the barometer is low or falling if they can avoid 
it. An inquiry undertaken by the writer in 1876, in which the 
excellent records of the Massachusetts General Hospital and* the 
observations of the Boston station of the United States Signal 
Service for five years were used as the basis of comparison, 
resulted negatively. The deaths following operations done on 
days when the barometer was high or rising were exactly equal 
in number to those following operations when the barometer 
was low or falling. Unfortunately, the investigation was never 
pursued to the extent of including other meteorological elements, 
such as humidity, cloudiness, precipitation, etc. The numerous 
studies of the relations of variations of pressure to the progress 
of infectious diseases have also failed to yield any fruits of value. 
Whether the nerve-pains so frequently complained of, especially 
by elderly patients, during the progress of areas of low barometer, 
are due to the diminished pressure, or to the influence of some 
other meteorological factor, such as humidity or electrical con- 
dition, cannot yet be decided. 

Increased atmospheric pressure, as noticed in caissons, tun- 
nels, and mines, produces increase in frequency and depth of 
respiration, diminution in the number of beats and volume of 
the pulse, pallor of the skin, increase of perspiration (although 
Smith states that this is only apparent and due to lack of evapo- 
ration from the surface), increased appetite, and more abundant 
excretion from the kidneys. 

Among the distinctly pathological effects of increased at- 
mospheric pressure are rupture of the drum of the ear, pain in 
the frontal and maxillary sinuses, neuralgic pains, nausea, some- 
times vomiting and local paralyses. Dr. A. H. Smith 1 defines 
this collection of symptoms as " The Caisson Disease," and gives 
the following summary of its characteristic features : — 

"A disease depending upon increased atmospheric pressure, 
but always developed after the pressure is removed. It is char- 

1 The Physiological, Pathological, and Therapeutical Effects of Compressed Air, p. 47. 
Detroit, 1886. 



INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 13 

acterized by extreme pain in one or more of the extremities, and 
sometimes in the trunk, and which may or may not be associated 
with epigastric pain and vomiting. In some cases the pain is 
accompanied by paralysis more or less complete, which may be 
general or local, but is most frequently confined to the lower 
half of the body. Cerebral symptoms, such as headache and 
vertigo, are sometimes present. The above symptoms are con- 
nected, at least in the fatal cases, with congestion of the brain 
and spinal cord, often resulting in serous or sanguineous effu- 
sion, and with congestion of most of the abdominal viscera." 



INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 

Many of the derangements of health ascribed to high tem- 
perature are to a considerable degree due to other factors, promi- 
nent among which are high humidity, intemperance, overwork, 
and overcrowding. There can be little doubt, however, that the 
importance of the high temperature itself can hardly be over- 
rated. It has been generally accepted heretofore that a high 
temperature, together with a high relative humidity, is most 
likely to be followed by sun-stroke. A careful comparison in a 
series of deaths from sun-stroke in the city of Cincinnati in the 
summer of 1881 shows, however, conclusively that a very high 
mean temperature with a low relative humidity is more liable to 
be followed by sun-stroke than the high temperature when ac- 
companied by a high humidity. The same series of observa- 
tions also shows that the number of deaths was greater on clear 
days than on cloudy or partly cloudy days. 1 A corroboration 
of this result is found in the fact that sun-strokes very rarely 
occur on shipboard, at sea, where the relative humidity is 
always high. 

The direct influence of the sun's rays upon the skin pro- 
duces at times an erythematous affection which may run into a 

1 The Sun-stroke Epidemic of Cincinnati, O., during the Summer of 1881. A. J. Miles, 
Public Health, vol. vii, pp. 293-304. 



14 TEXT-BOOK OF HYGIENE. 

dermatitis if the insolation is prolonged. Artificial heat may 
produce similar effects. 

Diarrhceal diseases, both of adults and children, are much 
more frequent during hot than cold weather (and in hot than in 
cold climates), but it is probable that other factors aid in the 
production of these diseases besides the high temperature. 

Certain epidemic diseases are likewise more frequent in, or 
exclusively confined to, hot climates. These are cholera, yellow 
fever, and epidemic dysentery. Elephantiasis, malarial fevers, 
and certain skin diseases seem also to have some connection with 
a constantly high external temperature. The intimate relation 
between cause and effect is not clearly understood, although the 
belief is current that the origin and spread of such diseases 
depend upon the development of various parasitic organisms. 

Regarding the morbific effects of continued high tempera- 
tures, it is probable that an appropriate mode of life, proper 
diet, and suitable clothing would avert many of the bad conse- 
quences. Nevertheless, the fact remains that certain tropical or 
hot-weather diseases must be considered as primarily dependent 
upon high temperature, although the pathological effects may be 
due to an intermediate factor. It is not improbable that micro- 
organisms will be found to explain yellow fever, cholera infan- 
tum, malarial fever, and tropical dysentery. Cholera has already 
been shown to depend upon a pathogenic organism. In this 
case the high temperature is one of the associate, but none the 
less indispensable, factors in the production of the disease. 

Extreme low temperature, as observed in the arctic regions, 
seems to produce a progressive deterioration of the blood 
(anaemia), in consequence of which most natives of temperate 
regions who are compelled to remain in the far north longer 
than two winters succumb to various hsemic diseases, scurvy be- 
ing the most prominent. It is not improbable, however, that the 
dietary furnished is responsible for a large share of the evil 
effects ascribed to cold. The absence of sunlight for a consider- 
able part of the winter season may also have much to do with 



INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 15 

the bad influences for which the low temperature is held 
responsible. 

Among the acute effects of great cold, frost-bite is the most 
frequent as well as the most serious. Loss of portions of the 
nose, or ears, or even of entire members are not infrequent 
results of frost-bite. 

In the arctic regions one of the most annoying affections 
which the traveler has to contend against is snow-blindness, a 
severe ophthalmia produced by the glare of the snow. Neutral 
tinted glass goggles should be worn as a preventive. 1 

Dr. Henry B. Baker 2 has placed upon record a large mass 
of observations which appear to indicate that most of the acute 
diseases of the respiratory organs are caused by a low tempera- 
ture in conjunction with a low absolute humidity. Dr. Baker 
furnishes numerous diagrams, which seem to demonstrate that 
the curves for influenza, tonsillitis, croup, bronchitis, and pneu- 
monia are in general outlines all practically the same, and that 
they follow the curve for atmospheric temperature with surpris- 
ing closeness, rising after the temperature falls and falling after 
the temperature rises. He claims that this sameness indicates 
that the controlling cause is one and the same for all of these 
diseases, and that, directly or indirectly, the atmospheric tem- 
perature is that cause. They are diseases of the air-passages, 
and may be supposed to be influenced or controlled by the at- 
mosphere which passes through them. Although the curves are 
all similar, yet their differences still further support his view, 
because the order of succession of the several diseases is such 
as would be expected if caused in the manner which he sup- 
poses. Thus croup and influenza precede in time bronchitis 
and pneumonia ; the curve for bronchitis shows that disease to 
respond quicker than does pneumonia to the rise and fall of the 



1 See Payer's Narrative of the Austrian Arctic Voyage of 1872-74, pp. 250-3 and 317, for an 
account of the effects of cold on the organism, and on the best prophylactic measures to he 
adopted. The Report of the Surgeon-General of the U. S. Navy for 1880 also contains (pp. 350-8) 
a valuable memorandum by Ex-Surgeon-General Philip S. Wales, on Arctic Hygiene. 

2 Trans. Ninth International Med. Congress, vol. v. 



16 TEXT-BOOK OF HYGIENE. 

temperature. He suggests that the explanation of the causa- 
tion of these diseases has not been grasped before because one 
of the principal facts has not been apprehended, namely, the 
fact that cold air is always dry air ; on the contrary, it has been 
generally stated that when these diseases occur the air is cold 
and damp. He explains that while the cold air is damp rela- 
tively it is always dry absolutely, and he thinks that its bad 
effects on the air-passages are mainly through its drying effects, 
which can best be appreciated by reflecting that each cubic foot 
of air inhaled at the temperature of zero, F. [ — 17.8° C], can 
contain only J grain of vapor [1.33 grammes per cubic metre], 
while when exhaled it is nearly saturated at a temperature 
of about 98° F. [36.5° C], and therefore contains about 18 J 
grains of vapor [about 43 grammes per cubic metre], about 18 
grains of which have been abstracted from the air-passages. 
Thus cold air falling upon susceptible surfaces tends to produce 
an abnormal dryness which may be followed by irritation and 
suppuration. He claims that coryza is sometimes so caused. 
Under some conditions the nasal surfaces are not susceptible to 
drying, the fluids being supplied in increased quantity to meet 
the increased demand made by the inhalation of cold air. In 
that case an unusual evaporation of the fluid leaves behind an 
unusual quantity of non- volatile salts of the blood, such as 
sodium chloride, and an unusual irritation results ; he thinks 
influenza is the name commonly given to this condition. The 
effects which the inhalation of cold air has on the bronchial 
surfaces depend greatly upon how the upper air-passages have 
responded to the increased demand for fluids ; because, if they do 
not supply the moisture it must be supplied by the bronchial 
surfaces, in which case bronchitis results. Finally, if the de- 
mands for moisture made by cold air are not met until the air- 
cells are reached pneumonia is produced. 

These claims are partly supported and partly opposed by 
an elaborate paper by Dr. J. W. Moore. 1 According to the 

1 The Seasonal Prevalence of Pneumonic Fever, Trans. Ninth Internal Congress, vol. v. 



INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 17 

statistics furnished by this writer, bronchitis and pneumonia 
show a remarkable contrast as to seasonal prevalence. The sta- 
tistics of London and Dublin agree very closely upon this point. 
Bronchitis falls to a very low ebb in the third or summer quarter 
of the year (July to September, inclusive), when only 12 per 
cent, of the deaths annually caused by this disease take place 
in Dublin and only 11 per cent, in London. In the last or 
fourth quarter (October to December, inclusive) the percentage 
of deaths from bronchitis rises to 27 in Dublin and 30 in London. 
The maximal mortality occurs in the first quarter (January to 
March, inclusive), when it is 38 per cent, in both London and 
Dublin. In the second or spring quarter (April to June, inclu- 
sive) the bronchitic deaths decline to 23 per cent, in Dublin and 
21 per cent, in London. 

The mortality from pneumonic fever is differently distrib- 
uted throughout the year. In the summer quarter more than 
14 per cent, of the annual deaths referable to the disease are 
recorded in Dublin and more than 15 per cent, in London. 
In the first quarter the figures are — London, 31 per cent.; 
Dublin, 31 per cent. In the second quarter they are — London, 
26 per cent. ; Dublin, 30 per cent. In the fourth quarter they 
are — London, 27 per cent. ; Dublin, 24 per cent. 

It therefore appears that the prevalence and fatality of pneu- 
monic fever from season to season do not correspond with the 
seasonal prevalence and fatality of bronchitis. The latter dis- 
ease increases and kills in direct relation to the setting in of cold 
weather ; it subsides in prevalence and fatality with the advance 
of spring and the advent of summer. Pneumonic fever, on the 
other hand, increases less quickly in winter and remains more 
prevalent in spring than bronchitis ; its maximal incidence coin- 
cides with the dry, harsh winds and hot sunshine of spring, 
when the diurnal range of temperature also is extreme. 

Dr. Moore believes that acute bronchitis is produced directly 
by the influence of low temperature, while pneumonia requires 
an additional cause, which he supposes to be a specific micro- 
organism. 2 



18 TEXT-BOOK OF HYGIENE. 

HUMIDITY OF THE ATMOSPHERE AS CONNECTED WITH CHANGES IN 

HEALTH. 

The propagation of certain acute infectious diseases is be- 
lieved to be due to a high relative humidity. There can be no 
longer any doubt that a very humid soil and air, especially if 
connected with a variable temperature, are almost constant 
factors in the production of pulmonary phthisis. Recent experi- 
ence in this country and abroad has shown that the high plateaus 
and mountains, far inland, where the soil is dry and the relative 
humidity of the air low, are the best resorts for consumptives. 

Of the effects of excessively dry air on health little definite 
is known. It seems probable, however, that catarrhal affections 
of the respiratory mucous membrane are more frequent in a dry 
than in a humid climate. 1 

THE SANITARY RELATIONS OF AIR-CURRENTS. 

Primarily, winds or air-currents may be considered as favor- 
able to health. By the agitation of the air ventilation is secured, 
foul air removed from insanitary places, and diluted by ad- 
mixture of purer air. But air-currents may also be regarded as 
either directly or indirectly unfavorably influencing health. 
Vertical currents rising from the ground may carry morbific 
germs or viruses and give rise to disease. Horizontal currents 
or winds proper may also be the direct or indirect cause of de- 
rangements of health. 

Full credit is given by the public to cold winds and draughts 
in producing catarrhs and rheumatic pains. The progression of 
certain infectious diseases, especially malaria, is believed with 
good reason to stand in a definite relation with the direction of 
the wind. 

Certain local winds are known to have a deleterious effect 
upon living beings, especially when the latter are in bad health. 
Among these winds is the mistral, a cold, dry, parching north- 

1 See ante. 



SANITARY RELATIONS OF AIR-CURRENTS. 19 

west wind which blows along the Gulf of Lyons. It brings on 
rheumatism and muscular pains, and is said to excite pleurisy 
and pneumonia and to act unfavorably upon consumptives. 

The bora is a cold, dry wind coming down from the Alps 
and continuing across the Adriatic. 

The Texan northers are well known in the southwestern 
part of the United States. They are extremely dry, and are 
often accompanied by a sudden fall of temperature. Changes 
of 28° C. (50° F.) within twelve hours are not infrequent in 
Western and Central Texas. Both man and beast suffer in- 
tensely from the cold, parching character of the wind. 

The sirocco of Northern Africa, Sicily, and Southern Italy 
has a world-wide notoriety for its depressing effect upon human 
energy. The liarmattan is equally noted on the west coast of 
Africa. It is hot and dry, while in Southern Europe the sirocco 
is hot and moist. 

The simoon is a hot, scorching wind of India, and is said 
to be deadly in its effects upon vegetation and extremely dele- 
terious to men and animals who are encountered by it. In 
Australia and South Africa hot winds are said to occur which 
completely destroy vegetable life in their track, and are often 
unwholesome in their effects upon animal life. 

The evil reputation of the Alpine fblin is very well known, 
and neither native nor traveler is anxious to encounter it. It is 
warm and dry. 

With reference to the influence of electrical conditions of 
the atmosphere upon health, no observations have been made 
which justify definite conclusions. 1 

Mr. Alexander Buchan and Dr. Arthur Mitchell have 
analyzed the influence of the weather and season upon the 

1 Dr. S. Weir Mitchell has shown, from the record of the case of Captain Catlin, IT. S. A € 
(American Journal Med. Sci., April, 1877, and N. Y. Med. Jour., August 25 and September 1, 1S83), 
that attacks of neuralgia — in this case, at all events — accompanied the progress of storms across 
the continent. Also, that the periods of maximum pain occurred with a high but falling barom- 
eter and increasing absolute humidity. There seems also to be some relation in this case between 
the maximum pain and the maximum magnetic force as shown by the declinometer. Dr. 
Mitchell's papers are among the most valuable positive contributions to hygienic meteorology, 
and deserve careful study. 



20 TEXT-BOOK OF HYGIENE. 

causation of disease, or, rather, upon the mortality from various 
diseases. 1 Taking the records of the city of New York from 
1871 to 1877, it appears that the maximum number of deaths 
from small-pox occurred in May, the minimum in September. 
From measles there were two annual maxima and minima, the 
greater in July and September and the smaller in February and 
April. From scarlet fever the maximum was in April, the mini- 
mum in September. From typhoid fever the maximum was 
from August to November, the minimum almost equally distrib- 
uted throughout the rest of the year ; from diarrhoea, the maxi- 
mum in July and August, the minimum from December to 
March ; from diphtheria, the maximum in December, the mini- 
mum in August ; 2 from whooping-cough, maximum in Septem- 
ber and February, minimum in November and June ; for croup 
the curves agree pretty closely with the diphtheria curves ; from 
phthisis, the maximum in March, minimum in June. 

The following charts, reproduced by permission of the 
Massachusetts State Board of Health from the report of that 
body for 1888, show an almost identical movement of the 
mortality from different diseases throughout the year. They 
exhibit the reported mortality for 1888 and also for the six years 
from 1883 to 1888. 

From suicide, curiously, the greater number of deaths occurs 
in May, the smallest in February. This is contrary to the usual 
supposition that gloomy weather predisposes to suicide. The six 
summer months — from April to September — show a much larger 
number of self-murders than the remaining half-year. In eleven 
years, ending 1880, there were 1521 cases of self-destruction in 
New York. Of these 341 occurred during January, February, 
and March; 417 during April, May, and June; 412 during 
July, August, and September; and 351 during the last three 
months of the year. In Philadelphia, the results of examination 

1 Journal Scottish Meteorological Society, 1875-78. (Abstract in Richardson's Prevent* 
ive Medicine, p. 533 et seq. Philadelphia, 1884.) 

2 See paper on the Relation of Weather to Mortality from Diphtheria in Baltimore, 
by Richard Henry Thomas, in Trans. Med. and Chir. Faculty of Maryland, 1883. 



INFLUENCE OP SEASON UPON MORTALITY. 



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26 TEXT-BOOK OF HYGIENE. 

of the statistics of suicide for ten years are almost exactly 
similar. Out of 636 cases of suicide, 78 occurred in May, 71 in 
August, 57 in December, 54 each in October, July, and April, 
52 in June, 49 in November, 44 each in December and Feb- 
ruary, 43 in March, and 36 in January. 1 Dr. Lee is led to be- 
lieve that " a low barometric pressure, accompanied by a high 
thermometric registry, with sudden fluctuations from a low to a 
high temperature, together with much moisture and prevailing 
southwest winds, might somewhat account for the frequency of 
self-murder in the spring and summer months." 

THE SANITARY RELATIONS OF CHANGES IN COMPOSITION AND OF 
IMPURITIES IN THE AIR. 

The average proportion of carbon dioxide in the atmosphere 
is from 3 to 4 parts in 10,000. Pettenkofer 2 places the maxi- 
mum limit of carbon dioxide allowable in the air of dwellings 
at 7 parts in 10,000. It is probable that this limit is very fre- 
quently exceeded without serious consequences to health, if the 
air is not at the same time polluted by organic impurities, the 
products of respiration. Prof. William Ripley Nichols found 
the air in a school-room in Boston to contain eight times the 
normal proportion of carbon dioxide, while Pettenkofer found, 
also in a school-room, after the same had been occupied two 
hours, eighteen times the normal proportion, or 72 parts in 
10,000. 3 While such an excess of this poisonous gas must 
unquestionably have an unfavorable influence upon health, it is 
probable that the most serious effects are due to the coincident 
diminution of oxygen and the pollution of the air by the prod- 
ucts of respiration which necessarily take place during respira- 
tion. Carbon dioxide alone may be present in the air to a much 
greater extent than above mentioned without causing any appre- 
ciable inconvenience. In the air of soda-water manufactories 

1 Suicide in the City and County of Philadelphia during a Decade, 1872 to 1881, inclusive, 
by John G. Lee, Trans. Am. Med. Asso., vol. xxxiii, p. 425. 

2 Quoted in Buck's Hygiene and Public Health, vol. i, p. 615. 

s See table in Buck's Hygiene and Public Health, vol. i, p. 612. 



SANITARY RELATIONS OF IMPURITIES IN THE AIR. 27 

there is frequently as large a proportion as 2 per cent, of this 
gas present without producing any ill effects upon those breathing 
such an atmosphere. 

The amount of carbon dioxide in the atmosphere is greatest 
at night. It is also greater very near the ground than at a dis- 
tance of several feet above it. As carbon dioxide is absorbed 
by the leaves of plants during the day-time, but given off at 
night, the difference may partly be thus accounted for. Accord- 
ing to Fodor, 1 the source of a large proportion of the carbon 
dioxide in the air is the decomposition going on in the soil. 
This accounts for the larger percentage of carbon dioxide near 
the ground. This would also explain the variation of the pro- 
portion of carbon dioxide in the air under different meteoro- 
logical conditions. For example, it is found that during rainy 
weather the carbon dioxide in the air is diminished. This is 
accounted for partly by the absorption of the carbon dioxide 
by the saturated ground, while at the same time the porosity 
of the soil is diminished and the escape of the ground-air 
prevented. 

Mr. R. Angus Smith made a number of experiments upon 
himself to determine the effects of an atmosphere gradually 
becoming charged with the products of respiration and per- 
spiration. His experiments were conducted in a leaden cham- 
ber holding 5 cubic metres of air. This air was not changed 
during the experiment. After remaining for an hour in this 
chamber, an unpleasant odor of organic matter was perceptible 
on moving about. The air, when agitated, felt soft, owing, 
doubtless, to the excess of moisture contained in it. The air 
soon became very foul, and, although not producing any dis- 
comfort, the experimenter states that escape from it produced a 
feeling of extreme pleasure, like " that which one has when 
walking home on a fine evening after leaving a room which has 
been crowded." 2 

1 Hygienische Untersuchungen ueber Luft, Boden und Wasser, Braunschweig. 1882, 
2te Abth. 

8 Air and Rain, p. 138. 



28 TEXT-BOOK OF HYGIENE. 

Hammond 1 confined a monse in a large jar in which were 
suspended several large sponges saturated with baryta water, to 
remove the carbon dioxide as rapidly as formed. Fresh air was 
supplied as fast as required. The aqueous vapor exhaled was 
absorbed by calcium chloride. The mouse died in forty-five 
minutes, evidently from the effect of the organic matter in the 
air of the jar. The presence of this organic matter was demon- 
strated by passing the air through a solution of potassium per- 
manganate. 

The horrible story of the "black hole" of Calcutta is 
familiar to every one. Of 146 prisoners confined in a dark cell 
at night, 23 were found alive in the morning. Among the sur- 
vivors a fatal form of typhus fever broke out, which carried off 
nearly all of them. After the battle of Austerlitz 300 prisoners 
were crowded in a prison ; 260 died in a short time from inhal- 
ing the poisoned air. Numerous other similar examples of the 
effects of polluted air are recorded. 

Usually the effects of foul air are not so sudden and strik- 
ing. In most instances, especially where the pollution has not 
reached a high degree, there simply results a general deficiency 
of nutrition, which manifests itself in anaemia, loss of vigor of 
body and mind, and a gradual diminution of resistance to 
disease. 

It seems to be beyond question that persons who are con- 
stantly compelled to inhale impure air, especially if combined 
with an improper position of the body or lack of sufficient or 
appropriate food, furnish a very large percentage of chronic pul- 
monary affections. Phthisical patients, in the overwhelming 
majority of cases, are drawn from the classes whose occupations 
keep them confined in close rooms. Want of exercise and of 
good food doubtless aid in the development of the lung disease. 
Formerly, when less attention was paid to the proper construc- 
tion and ventilation of barracks and prisons, the mortality from 

1 A Treatise on Hygiene, with Special Reference to the Military Service, by William A. 
Hammond, M.D., Surgeon-General U. S. Army, p. 170. Philadelphia, 1863. 



SANITARY RELATIONS OF IMPURITIES IN THE AIR. 29 

phthisis among soldiers and criminals was much greater than it 
is now. In animals kept closely confined the same disease claims 
a large share in the mortality. 

Near the end of the last century over one-third of the in- 
fants born in the old Dublin Lying-in Hospital died of epidemic 
diseases. After the adoption of an improved system of ventila- 
tion the mortality fell to about one-tenth of what it had pre- 
viously been. To illustrate the effect of similar conditions upon 
the health of domestic animals, the following instance is cited : 
Upward of thirty years ago a severe epidemic of influenza in 
horses appeared in Boston. At the instigation of Dr. H. I. 
Bowditch, every stable in the city was inspected, and classified 
as " excellent," " imperfect," or " wholly unfit," in respect to 
warmth, dryness, light, ventilation, and cleanliness. It was 
found that in the first class fewer horses were attacked and the 
disease was milder, while in the third class every horse was 
attacked and the more severe and fatal cases occurred. 

Carbon monoxide is a very dangerous impurity often 
present in the air of living-rooms. Being an ingredient of 
illuminating gas, as well as the so-called coal-gas, which so 
frequently escapes from stoves and furnaces, its dangerous char- 
acter becomes apparent. Many persons die every year in this 
country from the -inhalation of illuminating gas. People un- 
acquainted with the mechanism of the gas-fixtures frequently 
blow out the light instead of cutting off the supply of gas by 
turning the stop-cock. It is also a prevailing custom to keep 
the light burning " low " during the night. Any considerable 
variation of pressure in the pipes, or sudden draught, may put 
out the light and permit the gas to escape into the room, with 
fatal effect. Leaks in pipes or fixtures may have the same results. 

Coal-, coke-, or charcoal- fires may produce serious or fatal 
poisoning if the gas, which contains a large proportion of car- 
bon monoxide, is permitted to escape into the room. 1 In 

1 See paper by Dr. John Graham in Transactions of Philadelphia College of Physicians 
for 1885. 



30 TEXT-BOOK OF HYGIENE. 

certain parts of Europe, notably in France, the inhalation of the 
fumes of a charcoal fire is a favorite method of committing 
suicide. 

The gas which sometimes escapes from the stove when coal 
is burning has the following composition : — 

Carbon dioxide, 6.75 per cent. 

Carbon monoxide, 1.34 " 

Oxygen, ....... 13.19 " 

Nitrogen, 19.72 " 

Sulphuretted and carburetted hydrogen are not infrequently 
present in the air, especially about cess-pools and in mines and 
certain manufacturing establishments. Sulphuretted hydrogen 
is generally considered to be a violent poison, but there is no 
evidence that it is so unless oxygen is excluded. 

Carburetted hydrogen is the so-called "fire-damp" of 
mines, which is so often the cause of fatal explosions. Its in- 
halation does not seem to be especially noxious. It will be 
more fully referred to in a succeeding chapter. 

Variations in the proportion of ammonia present in the air 
are frequent. Its presence is an indication of organic decom- 
position in the vicinity, but nothing is known of the influence 
of the gas itself upon health, in the proportion in which it is 
ever found in the atmosphere. 

SEWER-AIR. 

Sewer-air, or sewer-gas, as it is often improperly called, is 
a variable mixture of a number of gases, vapors, atmospheric 
air, and solid particles, and is derived from the decomposition of 
the animal and vegetable contents of sewers. A number of 
analyses by different chemists have shown that the composition 
of sewer-air is extremely variable. The most important com- 
ponents, in addition to the constituents of atmospheric air, are : 
Carbon dioxide, ammonia, sulphuretted hydrogen, and a number 
of volatile organic compounds, which give to sewage its peculiar 
odor, but which are present in such small quantity as to prevent 



SEWER- AIR. 31 

accurate determination by chemical means. Sewer-air may also 
contain particulate bodies, bacteria, and other microscopic or- 
ganisms, which are supposed by many to be the active causes 
of infectious diseases. Some recent researches by Carnelly and 
Haldane have shown that sewer-air usually contains a less 
number of micro-organisms than the external air of cities. The 
proportion of carbon dioxide found was also much less than was 
expected. When the contents of sewers remain in these re- 
ceptacles or conduits long enough to undergo decomposition, 
sewer-air is always present. It is believed by some physicians 
and sanitarians that sewer-air is the direct cause of such diseases 
as typhoid fever, scarlet fever, diphtheria, and cholera, while 
others hold the view that the sewer-air is merely a favorable 
breeding-place for the germs of these diseases, and that it thus 
merely acts as a medium in which the infective agent grows, re- 
produces itself, and is conveyed from place to place. There is 
no absolutely trustworthy evidence in favor of either of these 
doctrines. 

It is hardly open to question, however, that the continual 
breathing of air polluted by emanations from sewers often pro- 
duces more or less serious derangements of health. Diarrhoea 
and other intestinal affections, mild cases of continued fever, and 
even cases of undoubted typhoid fever have been so frequently 
noted in connection with defective sewerage, and the escape of 
sewer-air into inhabited rooms, that doubt upon this point is 
hardly justifiable. With regard to typhoid fever, however, it is 
probable that the sewage in these cases contained the particular 
virus (bacillus ]) which, it is now generally believed, causes this 
disease. 

The effluvia from cemeteries, knackeries, and other places 
where the bodies of animals are undergoing decomposition, are 
popularly regarded as deleterious in their effects upon health. 
The evidence in favor of this view is, however, very indefinite. 

Professor Tyndall has shown 1 that even the apparently 

1 Essays on Floating Matter of the Air. New York, 1882. 



32 TEXT-BOOK OF HYGIENE. 

clearest air is, when in motion, constantly filled with innumerable 
particles of dust, which are believed by many to give rise to 
various forms of disease. The presence of these particles can 
be easily demonstrated by means of the electric light. Every 
one has observed these minute particles in a bright ray of sun- 
light. Under ordinary conditions these particles of dust would, 
of course, give rise to no trouble, but, if intermingled with these 
dust-specks there were disease germs, — whether these germs be 
considered as living organisms, or as particles of dead tissue 
from the body, — then manifestly the inhalation of such "dust" 
would be dangerous. 1 

The quantity of dust found in the air of cities is much 
greater than in the country. Tissandier found that in Paris the 
percentage of dust was eight to twelve times greater than in the 
open country. One-fourth to nearly one-half of this atmos- 
pheric dust is organic, either animal or vegetable. Very recent- 
observations have shown that in Paris the air contains nine or 
ten times as many bacteria in a given volume as the air at the 
observatory of Montsouris, just without the city. The relative 
proportions of organic and inorganic particles vary as 25 to 75 
in Paris, 45 to 55 in Dublin, and 25 to 75 in the open 
country. The organic particles are either particles of dead or- 
ganic matter, or minute organisms. The proportion of the 
latter varies in different seasons, being least in winter and 
spring, and greatest in summer and autumn. These organisms 
are not necessarily pathogenetic, but the conditions which favor 
the proliferation of non-pathogenic bacteria are likely to promote 
the development of disease-producing ones likewise. 

Among the pathogenic micro-organisms found in the at- 
mosphere are spores of achorion Schoenleinii, the so-called ma- 
laria bacillus of Klebs and Tommasi-Crudeli, and Fehleisen's 
erysipelas germ. It is probable, also, that the bacilli of tuber- 
culosis, cholera, and typhoid fever, and other organisms, at times 

1 See Chapter IX, on Industrial Hygiene, for effects of inhalation of dust in various 
industries. 



SEWER-AIR. 33 

undergo multiplication in the air, and that the latter may be the 
medium of communication of these diseases. But it must be 
admitted that our knowledge upon this point is at present 
rather vague and unsatisfactory. 

As regards the diseases that may be produced by the in- 
halation of pathogenic organisms there can be no doubt that 
diphtheria, glanders, measles, scarlet fever, whooping-cough, in- 
fectious pneumonia, and, above all, pulmonary tuberculosis, are 
so caused. It is likewise probable that yellow fever, epidemic 
influenza, cholera, and typhoid fever may be produced in this 
manner. 

TESTS FOR IMPURITIES IN THE AIR. 

The sense of smell will indicate the presence of sulphu- 
retted hydrogen, or of volatile organic matter. Chemical tests 
and the microscope will, however, be necessary to determine the 
presence of carbon dioxide, carbon monoxide, or suspended 
particulate matter in the air. 

In order to detect the presence of carbon dioxide, advantage 
is taken of the affinity of this compound for certain alkalies 
with which it forms insoluble compounds. If a stream of carbon 
dioxide gas is passed through lime- or baryta- water, an insoluble 
carbonate of lime or baryta is instantly formed, and produces a 
milky precipitate in the water. If, instead of passing a stream 
of gas through the liquid, the latter be agitated with air con- 
taining carbon dioxide, a similar precipitate is produced. The 
most exact method of determining the amount of carbon dioxide 
in the air is that known as Pettenkofer's, 1 but it is somewhat 
complicated. A readier method has been devised by Mr. Angus 
Smith, and is termed the minimetric test. 2 A series of six wide- 
mouthed bottles, having a capacity respectively of 450, 350, 300, 
250, 200, and 150 cubic centimetres, 3 is fitted with clean, tightly- 

1 Lehrbuch der Hygiene, Nowak, p. 149. 

2 Op. cit., p. 152. 

*The equivalents in English measures are 14 ounces, 11 ounces, 9% ounces, 8 ounces, 6% 
ounces, and 4% ounces. 

3 



34 



TEXT-BOOK OF HYGIENE. 



fitting corks. The bottles are made perfectly clean and dry, 

and 15 cubic centimetres (3| drachms) of clear, fresh lime- or 

baryta- water put into the smallest, the cork replaced, and the 

bottle well shaken. If the water becomes turbid there is at 

least .16 per cent. (16 parts per 10,000) of carbon dioxide 

in the air treated. If only the water in the largest bottle 

becomes cloudy, the proportion of carbon dioxide is probably 

less than 5 parts in 10,000. For the intermediate series of 

bottles the amounts of carbon dioxide necessary to produce 

cloudiness are, respectively: For 200 cubic centi- 

g \ metres of air, 12 parts in 10,000; for 250 cubic 

\l W centimetres, 10 parts; for 300 cubic centimetres, 

8 parts; and for 350 cubic centimetres, 7 parts per 

10,000. If, therefore, a cloudiness is produced with 

any of the bottles except the largest, the amount 

of carbon dioxide present exceeds the standard 

allowable in pure air. The test should be frequently 

made, in order to acquire familiarity with its use. 

The same quantity of the test-liquid is, of course, 

used in each bottle. 

A simple and easily-managed instrument, 
called an "air- tester, "has been devised by Professor 
Wolpert, a distinguished German meteorologist. It 
is described as follows by Dr. S. W. Abbott, who 
first called attention to its merits in this country 1 : 
The little instrument consists of a simple rubber bulb 
(A) of a capacity of 28 cubic centimetres, a glass outlet-tube (B) 
with a constriction near its extremity (E). A glass test-tube, 
12 centimetres in length (C) and 2 millimetres in diameter, has 
a horizontal mark near the bottom, indicating the point to which 
it must be filled with perfectly clear lime-water, to contain 
3 cubic centimetres. The bottom of the tube is whitened and 
has a black mark stamped upon it (D). A small, wooden stand, 
a brush or swab, a vial of vinegar for cleaning the tube, and a 
bottle of clear lime-water complete the outfit. 

1 Boston Med. and Surg. Journal. 



I 



E *£C 



Fig. 2. 

Air-Tester. 



TESTS FOR IMPURITIES IN THE AIR. 35 

In order to use the instrument, the lime-water (saturated 
solution) should be poured into the test-tube till it reaches the 
horizontal mark. Press down the bulb with the thumb, so as 
to expel the air within it as completely as possible, and allow it 
to fill with the air of the apartment, insert the small tube into 
the lime-water nearly to the bottom, and again expel the air 
with moderate rapidity, so that the bubbles may rise nearly to 
the top of the tube, but do not overflow, taking care to continue 
the pressure of the thumb till the small tube is removed from 
the lime-water. Repeat this process until the mark upon the 
bottom of the test-tube is obscured by the opacity produced by 
the reaction of the carbonic acid upon the lime-water, the observer 
looking downward through the lime-water from the top of the 
test-tube. 

With very foul air it is necessary to examine the mark after 
filling and discharging the bulb a few times only ; with good air, 
it must be filled twenty-five times and upward. 

The bulb represented in the cut is made a little larger than 
the required capacity, since a small amount of residual air 
usually remains in the bulb and cannot be expelled without 
great care. 

After each observation, the test-tube must be washed out 
and wiped dry. If a white incrustation forms upon the tube, it 
may be easily removed with a little vinegar, after which the 
tube should be thoroughly washed with pure water and dried. 

If the mark becomes obscured after filling the bulb ten or 
fifteen times only, the air of an .apartment is unfit for continuous 
respiration. 

In a sick-chamber the air should be so pure that the tur- 
bidity of the lime-water will not render the mark invisible until 
thirty or forty fillings are made. 

The instrument should be used by daylight, over a white 
ground, as a sheet of writing-paper, and care should be taken 
not to vitiate the result by the observer's own breath. 

The following approximate table is taken from the article 



36 



TEXT-BOOK OF HYGIENE. 



by Professor Wolpert, the first column representing the number 
of fillings of the bulb, and the second column the parts per 
10,000 of carbon dioxide in a given sample of air: — 



Number of 


Carbon Dioxide 


Number of 


Carbon Dioxide 


Number of 


Carbon Dioxide 


Fillings. 


per 10,000. 


Fillings. 


per 10,000. 


Fillings. 


per 10,000. 


1 


200. 


21 


9.5 


41 


4.9 


2 


100. 


22 


9.1 


42 


4.8 


3 


67. 


23 


8.7 


43 


4.6 


4 


50. 


*24 


8.3 


44 


4.5 


5 


40. 


25 


8. 


45 


4.4 


6 


33. 


26 


7.7 


46 


4.3 


7 


29. 


27 


7.4 


47 


4.2 


8 


25. 


28 


7.1 


48 


4.1 


9 


22. 


29 


6.9 


49 


4.1 


10 


20. 


30 


6.6 


50 


4. 


11 


18. 


31 


6.4 


51 


3.9 


12 


16. 


32 


6.3 


52 


3.9 


13 


15. 


33 


6.1 


53 


3.8 


14 


14. 


34 


5.9 


54 


3.7 


15 


13. 


35 


5.7 


55 


3.7 


16 


12.5 


36 


5.5 


56 


3.6 


IT 


12. 


37 


5.4 


57 


3.5 


18 


11. 


38 


5.3 


58 


3.5 


19 


10.5 


39 


5.1 


59 


3.4 


20 


70. 


40 


5. 


60 


3.3 



Carbon monoxide is detected by its reaction with palladium 
chloride, which gives a black color when brought in contact 
with the gas. If a strip of linen or blotting-paper be moistened 
with a solution of the palladium chloride (1 to 500) and sus- 
pended in air containing carbon monoxide, the black color will 
be developed. The suspected air may also be passed through a 
solution of sodio-chloride of palladium, when the liquid will 
turn black if carbon monoxide be present. 

The percentage of organic impurity in the air of an occu- 
pied room (products of respiration, etc.) is difficult to ascertain 
directly. 

Pettenkofer has found, however, that the proportion of 
carbon dioxide present is indirectly a measure of the organic 
impurity from respiration. As the determination of the carbon 



TESTS FOR IMPURITIES IN THE AIR. 37 

dioxide is easy by the minimetric method of Angus Smith, or 
the ready method of Wolpert, the extent to which the air is 
polluted by respiratory impurities is readily ascertained. 1 

The presence of organic and other suspended impurities 
can be best demonstrated with a microscope. An objective, mag- 
nifying upward of 400 linear diameters, and experience in the 
use of the instrument will be needed to obtain correct results. 
By moistening a glass slide with glycerin and exposing it in 
the suspected air, a sufficient quantity of the suspended matters 
may be collected in the course of twenty-four hours to permit 
some conclusions to be drawn from a microscopic examination. 2 

A common method of determining the presence or absence 
of a large quantity of carbon dioxide, for example, at the bottom 
of a well or privy- vault is to lower a lighted candle to the 
bottom. If the light is extinguished, the air is considered irre- 
spirable ; but, if it continue burning brightly, the air is believed 
to be sufficiently pure to sustain life. Sulphuretted hydrogen 
and sulphide of ammonium are sometimes found in privy- vaults, 
and, although they will not extinguish a light, they speedily 
prove fatal if inhaled in a concentrated form, and to the exclu- 
sion of a sufficiency of oxygen. 3 Cases have frequently occurred 
where serious or fatal results ensued from the presence of a dan- 
gerous gas, which was thought to be excluded by the burning 
candle. 

1 Recent observations in this country (see Annual Reports of the Surgeon-General of 
the Navy for 1879, pp. 45 and 46, and the same for 1880, pp. 31 to 34) seem to throw some doubt upon 
the entire reliability of this method of determining the amount of organic matter in the air 
examined. Prof. Ira Remsen (Report National Board of Health, 1879, p. 77, and 1880, p. 308 et 
seq.) has shown the insufficiency of the chemical methods at present in use, and points out the 
difficulties of making trustworthy and satisfactory determinations of organic matter in the air. 
The great technical difficulties of the various analytical processes render it unwise to burden 
these pages with a description of them. Only expert chemists are qualified to make a thorough 
air analysis, and the author does not feel competent to offer advice to them. Dr. Cornelius B. 
Fox's book on " Sanitary Examinations of Water, Air, and Food," and Fliigge's "Lehrbuch der 
Hygienischen Untersuchungsmethoden " contain detailed descriptions of the best methods 
employed. 

2 Dr. G. M. Sternberg, IT. S. A. (Report National Board of Health, 1880) , gives an ac 
count of his investigations into the suspended matters of the air. The question is also con- 
sidered in a practical manner by Surgeons Kidder and Streets, U. S. N., in Reports of the 
Surgeon-General of the Navy for 1880 and 1881. See also Bacteria, Sternberg and Magnin, 
2d ed., p. 197. 

* See a case reported in Philadelphia Medical Times, October 21, 1882. 



38 TEXT-BOOK OF HYGIENE. 

It is advisable in all cases to exhaust the stagnant air in 
old wells and privy-vaults before permitting any one to descend. 
Perhaps the readiest method of exhausting the vitiated air in 
such places would be to lower heated stones, masses of hot iron 
or pails of hot water, to near the bottom, which produce a rare- 
faction of the air and cause it to ascend. Its place will then be 
occupied by purer air from without. The rarefaction produced 
by the explosion of gun-powder has also been made use of with 
success ; but this has some objections, because the combustion 
of powder itself produces gases which are noxious if breathed 
in large quantity. An animal, such as a cat or dog, should be 
first lowered into the suspected well for fifteen or twenty min- 
utes, in order to determine whether the air at the bottom is 
capable of sustaining life, before permitting the workmen to 
descend. Similar precautions should be used in old, long- 
unused mines to prevent fatal effects from the so-called " choke- 
damp," which is largely composed of carbon dioxide. 

PRINCIPLES OF VENTILATION. 

During ordinary respiration an adult human being adds 
900 grammes == 455,500 cubic centimetres (14 cubic feet) of 
carbon dioxide to, and abstracts 744 grammes == 516,500 cubic 
centimetres (16 cubic feet) of oxygen from, the atmosphere in 
twenty-four hours. Hence, if the individual were confined in 
an apartment where the inclosed air could not be intermingled 
by diffusion with the atmosphere without, the proportion of 
carbon dioxide would soon become so great that the processes 
of life could not be sustained, and the individual would die. 
This result would be reached even sooner than the point here 
mentioned, for the organic matter exhaled from the lungs and 
the surface of the body would increase the poisonous condition 
of the air even more than the carbon dioxide given off. It is 
easily seen, therefore, how important the study of the principles 
and practice of ventilation becomes in hygiene. In this chapter 
only the principles underlying this subject can be definitely 



PRINCIPLES OF VENTILATION. 39 

stated. Practical details will be more fully given in the chapters 
devoted to dwellings, schools, hospitals, etc. 

It is generally accepted among sanitarians that the presence 
of .07 per cent. (7 parts in 10,000) of carbon dioxide in the air 
indicates the greatest amount of organic impurity (from respira- 
tion or combustion) consistent with the preservation of health. 
As each individual gives off from his lungs, in the process of 
respiration, 316 cubic centimetres of carbon dioxide per minute, 
the diffusion in the air surrounding him must be sufficiently 
rapid to keep the air to be breathed at the standard of .07 per 
cent, above mentioned. 

Adopting this as the standard of maximum impurity allow- 
able, 90 cubic metres of fresh air per hour will be needed for 
each individual to keep him supplied with pure air. This is for 
a person in a state of health ; in cases of disease a more rapid 
change of air will be necessary to keep that surrounding the 
patient in a state of purity. 

Ventilation is defined by Worcester as " the replacement 
of noxious or impure air in an apartment, mine, or inclosed 
space by pure, fresh air from without." By Dr. Parkes the 
term is restricted to " the removal or dilution, by a supply of 
pure air, of the pulmonary and cutaneous exhalations of men 
and the products of combustion of lights in ordinary dwellings, 
to which must be added, in hospitals, the additional effluvia 
which proceed from the persons and discharges of the sick. All 
other causes of impurity of air ought to be excluded by cleanli- 
ness, proper removal of solid and liquid excreta, and attention 
to the conditions surrounding dwellings." 1 

A proper system of ventilation must take into consideration 
the cubic space of the apartment or building to be ventilated, 
the number of persons ordinarily inhabiting this space, whether 
constantly or only temporarily occupied, and certain other col- 
lateral elements, such as the character of the building to be 
ventilated, its exposure, necessity for artificial heating, etc. 

1 Manual of Practical Hygiene, 6th ed., New York, vol. i, p. 157. 



40 TEXT-BOOK OF HYGIENE. 

The amount of cubic space that must be allowed to each 
individual is determined by the rapidity with which fresh air 
must be supplied in order to keep that surrounding the indi- 
vidual at the standard of less than .07 per cent, of carbon dioxide. 
For example, in a space of 3 cubic metres, the air must be 
changed thirty times in an hour, in order to prevent the carbon 
dioxide exceeding the above proportion ; that is to say, to allow 
90 cubic metres of air to pass through that space in the time 
mentioned. This would create an uncomfortable, if not injurious, 
draught. If the space contained 30 cubic metres, the air would 
need renewal only three times an hour. 

A space of 15 cubic metres could be kept supplied with 
pure air without perceptible movement if all the mechanical 
arrangements for changing the air were perfect ; but such per- 
fection is rarely attainable, and hence there would be either 
draughts or insufficient ventilation in such a small " initial air- 
space," as it is termed. The initial air-space should, therefore, 
be not less than 30, or, better, 40 cubic metres. The air of this 
space could be changed sufficiently often to keep it at its standard 
of purity without creating unnecessary draught. For sick per- 
sons this should be doubled. In hospitals, therefore, the cubic 
air-space allowed to each bed should not be less than 60 to 80 
cubic metres. 

As stated, the purposes for which the building or apartment 
to be ventilated are employed require differences in the cubic 
space and in the volume of fresh air supplied. Morin gives the 



bllowing table : — 




Table III. 


Fresh Air Required 
per Hour per Head. 


Hospital wards for ordinary cases, 
Hospital wards for surgical and obstet 

rical cases, 

Hospital wards for contagious diseases 
Prisons, . 


60-10 cubic metres. 

100 " " 

150 " " 

50 " " 



PRINCIPLES OF VENTILATION. 41 



Workshops, j ordinar y occupations, 
1 ' (unhealthy, " 

Barracks, /during the day, . 
1 " " night, . 

Theatres, 

Assembly rooms for long receptions, 

" " " brief " 
Primary schools, .... 
Higher " .... 
Stables 



60 cubic metres 


100 " 


t< 


30 " 


u 


40-50 " 


u 


40-50 " 


u 


60 " 


u 


30 u 


U 


12-15 " 


u 


25-30 " 


u 


180-200 " 


u 



These figures are not excessive from a sanitary stand-point, 
although few buildings meet the requirements here set down. 

The source of the air supplied must, of course, be capable 
of yielding pure air. It should not be drawn from damp cellars 
or basements, or from the immediate vicinity of sewers or drains. 
Air taken from such places is little better for respiration than 
that which it replaces in the apartments to be ventilated. 

Ventilation may be accomplished either with or without 
artificial aids. In buildings or rooms, used as habitations, 
natural ventilation (with, perhaps, the simplest mechanical aids) 
is made use of almost entirely. In large buildings, such as 
churches, theatres, schools, or in ships and mines, one of the 
artificial systems must be adopted if efficient ventilation is 
desired. 

Natural ventilation takes place by diffusion, by perflation, 
and in consequence of inequality of atmospheric pressure. By 
diffusion is meant the slow and equable entrance of air from 
without and exit from within a room through the walls or ill- 
made joints without the influence of wind-currents. In an 
occupied room this is, however, insufficient to keep the air pure, 
because many of the organic impurities of respired air are mole- 
cular, and, therefore, incapable of making their way out of the 
rooms through the walls. 

Perflation means, literally, " blowing through," and, if the 
direction and force of air-currents could be regulated, this would, 
with simple mechanical arrangements, be an efficient means of 



42 TEXT-BOOK OF HYGIENE. 

ventilation. However, the uncertainty of the force and direc- 
tion of the wind makes this method of ventilation untrustworthy, 
except in warm weather. 

Unequal pressure between the air in a room and that 
without is, within certain limits, an efficient means of ventila- 
tion, and is usually relied upon in ordinary apartments. When 
the air in a room is heated above the temperature of the external 
air, either by a fire, lights, or by the presence of a number of 
persons in the room, it expands, and part of it finds its way out 
through numerous crevices and bad joints found in all buildings. 
The air which remains, being less dense than the external air, 
the latter enters the room by various openings, until the equality 
of pressure is re-established. But as the heating of the enclosed 
air continues, the process is momentarily repeated and becomes 
continuous. 

Although the impurities of respired air (carbon dioxide, 
organic matter) are heavier than the air itself at the same 
temperature, it is a familiar fact that the most impure air in an 
occupied room is always found near the ceiling, the impurities 
being carried upward with the heated air, and that the pure air 
from without, being colder, fills the lower part of the room. 

If the cold, outside air were to be admitted at the bottom 
of the room, and means allowed for the escape of the hot air at 
the top, the conditions of the old health-maxim, to " keep the 
feet warm and the head cool," would be reversed, This would 
be no less uncomfortable than unwholesome. In all plans for 
natural ventilation, therefore, provision must be made to secure 
a gradual diffusion of the cold, outside air from above, or to 
have it warmed before it enters the room. With a large chimney 
as an aspirating shaft, 1 with flues at the top and bottom of the 
room, and openings in the walls of the room near the ceiling to 
admit fresh air, sufficient ventilation can be usually secured in 
cold weather, in a room not overcrowded. 

1 Of course there is really no such thing as a real aspiration, or "sucking out " of the air 
through the chimney or so-called "aspirating shaft." The upward movement of the air in the 
shaft is due to its displacement by the colder or denser air entering the room. 



PRINCIPLES OF VENTILATION. 43 

When a room is heated by a furnace, the fresh air is warmed 
before it is introduced, and the foul air escapes either through a 
ventilating shaft, a ventilator in the window or wall, or through 
the numerous fissures and other orifices which defective car- 
pentering always leaves for the benefit of the health of the 
occupants. 

The following rules for the arrangement of a system of 
natural ventilation are modified and condensed from Parkes 1 : — 

The apertures of entrance and of exit for the air should be 
placed far enough apart to permit thorough diffusion of the 
fresh air. 

When the air is brought into a room through slits or tubes 
in the walls near the ceiling, the current should always be 
deflected upward by an inclined plane, in order to prevent a 
mass of cold air from descending over the shoulders of the 
occupants and chilling them. 

The air must be taken from a pure source. 

The inlet-tubes should be short, and so made as to be easily 
cleansed, otherwise dirt lodges and the air becomes impure. 

Inlets should be numerous and small, to allow a proper 
distribution of the entering air. 

Externally, the inlets should be partially protected from 
the wind to prevent strong draughts ; they should also be pro- 
vided with valves to regulate the supply of air. 

If the air cannot be warmed, the inlets must be near the 
ceiling ; if it can be heated, it may enter near the floor. 

The air may be warmed by passing it through boxes con- 
taining hot water or steam coils, by passing it through chambers 
around grates or stoves, or heating it in a furnace. 

In towns or manufacturing districts the air should be 
filtered before allowing it to enter the room. Thin flannel or 
muslin spread over the openings answers very well as filtering 
material. 

Outlets should be placed at the highest point of the room 

1 Manual of Practical Hygiene, 6th ed., New York, vol. i, p. 177. 



44 TEXT-BOOK OF HYGIENE. 

and should be protected from the weather. An opening into the 
chimney near the ceiling will answer well in many cases. 

In one-story buildings, ridge-ventilators make the best out- 
lets. The entrance of snow and rain must be prevented by 
suitable arrangements. 

A small space or slit between the horizontal bars of the 
upper and lower window-sash will admit sufficient air in a proper 
direction in small rooms, even when the window is shut. 

In all rooms, howsoever ventilated, doors and windows 
should be often opened to permit a thorough flushing of the 
interior with fresh air. 

For large buildings, hospitals, schools, theatres, ships, and 
mines two systems of artificial ventilation are in use. One 
operates by extracting the foul air by means of fans, the other 
by forcing in fresh air, allowing the impure air to find its way 
out as best it may. 

Rotating cowls on the tops of chimneys may be used to 
increase the aspirating power of the air ; in this way the 
natural force of the wind may be utilized for ventilation of 
rooms or buildings of moderate size. 

Further details upon the practical application of these prin- 
ciples will be given in succeeding chapters of this work. 

[In addition to the works mentioned in the text the follow- 
ing may be referred to as more fully treating of the subjects 
considered in this chapter : — 

Flammarion : The Atmosphere. — The Articles on Atmosphere and 
Climate in the Encyclopaedia Britannica, 9th edition. — Reports of the 
Chief Signal Officer of the Army. — A paper on Climate and Diseases, by 
Dr. Cleveland Abbe, in Report of National Board of Health for 1880. — 
Die Canalgase, by Dr. F. Renk, Mnnchen, 1884. — Morin : On Warming 
and Ventilating Occupied Buildings; translated in Smithsonian Report 
for 1873 and 1874. — V. Pettenkofer und Ziemssen's Handbuch der Hy- 
giene, I Theil, 2 Abtheilung. Die Luft, by Dr. F. Renk.— A. Woeikof : 
Die Klimate der Erde, 1887. — B. W. James: American Resorts, 1889. — 
A. W. Gree^ : American Weather, 1888. — Jules Rochard : Questions 
d'H}rgiene Sociale ; L'Acclimatement dans les Colonies Francaises, 
1891.— Kenwood : The Hygienic Laboratory, Part III, 1893.] 



QUESTIONS TO CHAPTER I. 

Air. 

What is the composition of the atmospheric air ? Is the mixture a 
chemical or mechanical one ? What constituent is the most constant in 
proportion, and what ones most variable? What are the causes and 
limits of variation in the composition of the air? Has this variation any 
effect upon health ? 

How is the general uniformity of composition maintained ? What 
is the relation of the oxygen and carbon dioxide to plant and animal life 
and to one another ? 

What is the depth of the atmosphere ? What is its weight, and how 
is this measured ? How may you determine the altitude of any place 
above the sea-level ? 

What effect has temperature on barometric pressure ? What effect 
has moisture, and why ? Whence does the air derive its warmth ? 
Where is the atmosphere warmest ? 

What is the relation between the temperature and humidity of the 
air ? What is meant by " absolute " and " relative " humidity ? How is 
each always designated ? What is meant b} T " saturation "? 

What causes motion in air or wind ? What conditions of the atmos- 
phere probably have relation to, or influence upon, disease ? Wiry should 
a sanitarian be a practical meteorologist ? 

What are the physiological effects of diminution of atmospheric 
pressure ? What ma} T aggravate these effects ? To what are they due ? 
Can the human body become accustomed to them ? What name is given 
to this plrysiological disturbance ? What diseases will probabh' improve 
in a rarefied atmosphere, and what ones will not ? 

What are the effects of increased atmospheric pressure upon the 
organism ? Is there any danger of fatal results ? Have the diurnal 
variations of pressure saiy effect upon the bod}- in health or in disease ? 

What effect has high temperature upon health ? What diseases are 
more frequent in hot weather and in hot climates ? 

What peculiar affection seems to be caused or favored by long- 
continued exposure to cold? What are some of the acute effects of 

(45) 



46 QUESTIONS TO CHAPTER I. 

cold? What effect has the relative humidity in the production of these 
diseases? Indicate and explain a possible relationship of causation 
between coryza or influenza, bronchitis and pneumonia. Is this altogether 
substantiated by statistics? Is low temperature the only cause of pneu- 
monia ? 

What part has the relative humidity in the production of certain 
diseases? 

What is the general rule as to the effect of winds or air-currents 
upon health? Name some apparent exceptions to this rule. Has the 
season anything to do with the morbidity and mortality from different 
diseases ? Give examples. 

What is the average proportion of carbon dioxide in the atmos- 
phere ? What should be the maximum limit permissible in dwellings ? 
Is this limit often exceeded ? When exceeded, to what are the evil 
effects upon health probably due? How much carbon dioxide alone 
may be present in the atmosphere without producing any apparent 
ill effects ? 

When and where in the out-door atmosphere is the proportion of 
carbon dioxide greatest ? In what way may this be explained ? 

What are the products of respiration and perspiration, and which 
of these is most harmful to health ? What evidence have we to that 
effect? Have we any evidence that the respirator}^ carbon dioxide 
alone is harmful to health? Where there is a moderate degree of re- 
spiratory pollution, what are some of the symptoms usually produced 
thereby ? In the production of what especial disease has impure air a 
decidedly causative influence? 

^ Which is the more dangerous to health, carbon monoxide or carbon 
dioxide? Of what gases is the former an ingredient? How does it 
produce its harmful effects? 

Have sulphuretted and carburetted h} r drogen any effect upon health? 
If so, in what proportions must they be in the atmosphere? Has ammo- 
oia, in the proportion in which it is usually found in the atmosphere, any 
bad effect upon health? 

What is sewer-air or sewer-gas, and what are some of its constit- 
uents? In what way may it be the cause of infectious disease? Will 
the continued breathing of air polluted with sewer-gas affect health, and, 
if so, what symptoms may be caused thereby ? What must be necessarily 
present in the sewer-gas for it to be a cause of typhoid fever? 

Is there any positive evidence that the emanations from cemeteries, 
bone-yards, etc., are harmful to health? 



QUESTIONS TO CHAPTER I. 47 

What diseases may be produced by the inhalation of pathogenic 
micro-organisms carried by the air ? 

What tests have we for the various impurities in the air ? What 
reagents may be used to determine the presence and amount of carbon 
dioxide in the atmosphere ? Describe briefly the Angus Smith minimet- 
ric test and Wolpert's air-tester. What precautions must be observed 
with the latter? Wherein may each be improved? (See chapter on 
" Examination of Air, Water, and Food," page 413.) 

What reasrent is used to detect carbon monoxide ? Can the amount 
of respiratory organic matter in air be readily determined directly ? 
What discovery did Pettenkofer and de Chaumont make regarding the 
relation between the respiratory organic matter and carbon dioxide in 
the air ? 

How may the presence of quantities of carbon dioxide sufficient to 
endanger life be determined in wells or cess-pools, and how may such 
quantities of this gas be removed ? What other gases dangerous to life 
might be present in cess-pools and yet not be indicated by the above test ? 

Ventilation. — How much oxygen does an adult human being at rest 
ordinarily take from the air, and how much carbon dioxide does he add 
to it in twenty-four hours ? What percentage of carbon dioxide in the 
air indicates the greatest amount of organic impurity from respiration, 
etc., consistent with health? How much fresh air per hour is, therefore, 
needed by each individual to maintain this state of purity ? Will sick 
persons need more fresh air than the well ? Wh} T ? 

What is meant by ventilation ? What should be excluded from the 
term ? 

What matters must a proper sj^stem of ventilation consider? What 
governs the amount of cubic space that can be allotted to each individual ? 
What should be the minimum air-space for the well, and what for the 
sick? What should be the floor-space for each person, and why ? From 
what kind of a source must the air for a ventilation supply be taken? 

What is the difference between natural and artificial ventilation? 
What are the forces acting to produce natural ventilation ? What is 
meant b} T diffusion ? Why is it insufficient for ventilating an occupied 
room? What is meant by perflation? Why cannot it be used alone 
for ventilation ? Upon what does the inequality of atmospheric pressure 
depend ? Why is it the most valuable of the forces of natural ventilation ? 

In what part of an occupied room is the most impure air found, 
and why ? 

What precautions must be observed in all plans for natural ventila- 



48 QUESTIONS TO CHAPTER I. 

tion '( What makes the air from a room pass up a chimney? When a 
room is heated by a hot-air furnace, how does the foul or used air escape? 
What rules may be laid down for the arrangement of a system of natural 
ventilation ? 

Where should the fresh-air inlets of a room be located ? How may 
the air be warmed before bringing it into the room ? How should the 
inlet-tnbes be arranged? Where should the outlets of a room be located ? 

What systems of artificial ventilation may be employed for large 
buildings or rooms ? By what appliances may we make use of winds for 
ventilating purposes ? 






CHAPTER n. 

Water. 

Physiologists teach that nearly two-thirds of the tissue of 
the animal body consists of water. Inasmuch as this water is 
constantly being lost by evaporation from the skin, exhalation 
by the lungs, and excretion through various organs, it is evident 
that the loss must be constantly supplied if the functions of life 
shall be properly performed. 

It appears probable that certain diseases are at times spread 
through the agency of insufficient or impure drinking-water. 
It is, therefore, a matter of very great importance to have a defi- 
nite notion of what constitutes a pure and sufficient supply of 
water, and how best to secure it, to be able to detect its condi- 
tions of purity and impurity, and to know how to maintain the 
former and avoid the latter. It will be necessary to consider in 
detail, therefore, the quantity of water required by each indi- 
vidual for the maintenance of health, the sources whence water 
is obtained, how it should be collected and stored to the best 
advantage, the impurities likely to be contained in it, and the 
methods of keeping it pure, or of purifying it when it has 
become polluted or vitiated in any manner. 

THE QUANTITY OF WATER REQUIRED BY HUMAN BEINGS. 

Dr. Parkes, after a number of experiments, concluded that 
a man of the English middle class, "who may be taken as a 
fair type of a cleanly man belonging to a fairly cleanly house- 
hold," uses about twelve gallons of water per day. This covers 
all the water needed, including a daily sponge bath. Dr. 
DeChaumont estimates 1 that 16 gallons should be the daily 

1 Parkes' Hygiene, 6th ed., New York, vol. i, p. 5. 

4 (49) 



50 TEXT-BOOK OF HYGIENE. 

allowance. By order of the British War Department, 15 gal- 
lons of water are allowed to each soldier daily. In very many 
instances this quantity cannot be furnished, but in such cases 
there necessarily results some deficiency in cleanliness. It is 
probable that among the poorer classes, especially where a large 
supply of water is not convenient, the quantity used is not over 
one-fourth of the above estimate. 

In estimating the daily supply of water needed in a com- 
munity, large or small, other circumstances must be taken into 
consideration in addition to the demands of the individual. 
For example, in towns or cities allowances must be made for 
animals, manufacturing purposes, probable waste, fires, sewerage, 
etc. In cities an allowance of 50 gallons daily per head would 
not be excessive. In most American cities the supply is much 
greater. 1 The present daily supply in Baltimore, which is de- 
rived from an excellent source, is estimated at 60 gallons per 
head, which could be increased to three times that quantity if 
necessary. 

A serious problem, affecting, however, the engineer rather 
than the sanitarian, is the prevention of waste of water in places 
where the supply is limited. It is estimated that in Chicago 
one-half of the water pumped is wasted through negligence and 
imperfections in the supply apparatus, while in St. Louis the 
annual cost to the city of the water that is wasted is placed at 
$400,000. It has been proposed to check this wanton waste by 
measuring the quantity of water used by each household by 
means of a meter, as the supply of gas is now measured, and 
this has been carried into effect in places. There are, however, 
serious objections to this method. One of the objections is that 
the very class of persons whom it is desired to induce to use a 
plentiful supply of water would, from motives of economy, use 
less than is necessary for cleanliness and health. A system of 
vigilant inspection of the water service in houses would probably 
serve to reduce this unnecessary waste to a considerable extent. 

1 Buck's Hygiene and Public Health, vol. i, p. 214. 



SOURCES OF DRINKING-WATER. 51 

SOURCES OF DRINKING-WATER. 

All -water, from whatever direct source obtained, comes 
originally, by precipitation, from the atmosphere. In many 
places the rain- or snow- water is the only source of supply. This 
is usually collected as it falls upon the roofs* of buildings and 
conveyed by gutters and pipes to cisterns, where it is stored until 
needed. 

In Venice, the rain falling upon the streets and court- 
yards is also collected in cisterns after filtering through sand. 
The cisterns used for the storage of water in New Orleans and 
other Southern cities in the United States, where the tempera- 
ture rarely falls below the freezing-point, are generally con- 
structed of wood and placed above-ground. Farther north, 
where it is necessary to protect them against the action of frost, 
they are placed under-ground. These under-ground cisterns are 
usually built of brick. The water from cisterns above-ground 
becomes very much heated in summer, and necessitates the use 
of large quantities of ice to make it palatable. The water from 
the under-ground cisterns is pleasantly cool in summer, and is 
also guarded against freezing in winter, There are, however, 
very serious objections to storing drinking-water in under-ground 
cisterns. These reservoirs are usually placed within a few feet 
of privies and cess-pools, and, as neither the retaining walls of 
the cisterns nor those of the privies are water-tight, it often 
happens that the drinking-water becomes strongly impregnated 
with the soluble portions of the excrement, or the products of 
its decomposition, which have drained into the cistern. Per- 
sonal observations in Memphis in 1879, as well as the careful 
chemical analyses made afterward by Dr. Chas. Smart, U. S. A., 1 
have convinced the author that the objections to all under- 
ground cisterns built of brick, stone, or cement are insuperable 
from a sanitary point of view. Dr. Smart found over one-half 
of the under-ground cisterns examined by him in Memphis and 

1 Report National Board of Health, 1880, pp. 437-441. 



52 TEXT-BOOK OF HYGIENE. 

other cities and towns to be leaky and presenting evidence of 
organic pollution. The water from 31 out of 80 cisterns ana- 
lyzed showed decided contamination by sewage. It would seem 
advisable to prohibit all under-ground cisterns for the storage of 
drinking-water unless they are constructed of iron, which should 
be protected against oxidation by a thorough coating of coal- 
tar. Where any other system of collection and storage is avail- 
able, however, the under-ground cistern should be unreservedly 
condemned. 

Rain-water collected in the country, away from manufac- 
turing districts, is usually quite pure and wholesome. Its taste 
is, however, flat and insipid, owing to absence of carbon dioxide 
and mineral constituents. In cities rain-water frequently con- 
tains such a large amount of organic matter and other impurities, 
which have been washed out of the air by the rain, that it may 
be unfit for drinking. On account of its softness, rain-water is 
very desirable for washing and other domestic purposes. If the 
statement made in the last chapter, concerning the presence of 
organisms in the atmosphere, is remembered, it will be evident 
on a moment's thought that such organisms, when contained in 
rain-water, may be the source of disease. The putrefaction 
which so readily takes place in rain-water upon standing a few 
days is caused by certain of the organisms carried down out of 
the lower strata of the air by the descending rain or snow. 

Precipitation is an exceedingly untrustworthy source of 
water, and should never be depended upon when other sources 
of supply are available. Water famines are frequent wherever 
people are compelled to rely upon such an uncertain source of 
supply as rain or snow. 

Rivers and smaller streams probably supply the larger 
number of cities and towns in this country with drinking-water. 
When care is taken to prevent the pollution of the stream above 
the point whence the water is taken, this is usually of fair 
quality for domestic purposes. When the river can be tapped 
near its source, or before a large number of manufacturing 



SOURCES OF DRINKING-WATER. 53 

establishments can empty their waste products into its current, 
or before it receives the sewage of a considerable number of 
inhabitants living on its banks, the water can generally be re- 
garded as safe. It is very difficult, however, except in the less 
settled portions of the country, to find these favorable conditions 
present. 

Among the minor objections to the use of river-water for 
domestic purposes are the liability of most streams to become 
turbid in times of freshet, and the discoloration of the water 
from dissolved coloring-matters if the stream flows through a 
marshy or peaty region. These objections are, however, not 
serious, as filtration will readily remove the suspended matters. 
The coloring-matter is probably harmless. The organic matter 
contained in the water of some streams, even when pollution by 
sewage and manufacturing refuse is absolutely excluded, may, 
however, be the cause of disease. Dr. Smart has shown 1 that 
the water from streams in Nebraska, Wyoming, and Utah con- 
tained organic matter varying in amount from .16 to .28 parts 
per million. 2 He thinks the so-called " mountain fever " of the 
Rocky Mountain region is a malarial fever caused by the large 
amount of organic matter in the drinking-water. 

Dr. G. M. Kober, U. S. A., states that he has frequently 
drunk water from mountain streams which had a perceptible 
taste of cattle-manure, and suggests that as the origin of the 
ammonia found by Dr. Smart in the water of mountain streams. 
Dr. Kober also regards the "mountain fever" as a typhoid fever 
with malarial complications. 3 

The most serious objection to the use of river- water for 
domestic purposes is the employment of streams as carriers of 
refuse from manufacturing establishments, or of the sewage of 
cities and towns. In Great Britain and some parts of the con- 
tinent of Europe, owing to the density of population and the 

1 American Journal Med. Sciences, January, 1878, p. 28 et seq. 

* The source of this organic matter seems to be the melted snow which makes up a large 
portion of the streams. 

s Report of California State Board of Health for 1886, pp. 48 and 177. 



54 TEXT-BOOK OF HYGIENE. 

variety and extent of manufacturing industries, many of the 
streams are in an extremely filthy condition. In this country, 
too, especially in the more thickly settled manufacturing districts 
of New England, the pollution of rivers has increased to a 
degree to seriously jeopardize the health of the people who are 
compelled to draw their water-supply from such streams. Several 
years since a commission was appointed by the State Board of 
Health of Massachusetts to inquire into the extent of the pollu- 
tion of the streams in that State, and to devise means for pre- 
venting such pollution. The commission extended its inquiries 
and observations over several years, reporting the result to the 
State authorities at intervals. 1 It was found that the water of the 
Blackstone Biver, at Blacks tone, where it crosses the State line 
and enters Bhode Island, contained over 10 per cent, of sewage 
and refuse waters. 2 Other streams in Massachusetts show 
similar pollution. That the presence of such excessive con- 
tamination renders the water unsuitable for domestic pur- 
poses must appear evident. It is probable, however, that the 
most dangerous of the polluting matters are the excreta of 
human beings, especially those of patients suffering from certain 
specific diseases, such as typhoid fever or cholera. 

Only a few years ago it was a generally-accepted theory 
that running- water, though polluted by sewage, "purifies itself" 
after flowing a distance of twelve miles, and the comforting and 
reassuring doctrine is still held by many. Becent observations 
point to the conclusion, however, that the self-purification of 
rivers is not entirely to be relied upon. A certain proportion 
of the sewage, it is true, undergoes oxidation in the presence of 
light and air and minute organisms, 3 and so becomes changed 
into other, possibly innocuous compounds. But at present it is 
not known what proportion or what kind of organic matter 
does undergo this change. Another portion of the impurities 
is deposited upon the bottom and sides of the stream, having 

* Reports State Board of Health of Massachusetts for 1873, 1874, 1876, 1877, 1878, 1879, 1880. 
2 Report State Board of Health of Massachusetts, 1876, p. 145. 

• Desinfection, in Eulenhurg's Realencyclopaedie d. ges. Heilkunde, vol. iv, p. 68. 



SOURCES OF DRINKING-WATER. 55 

been only held in suspension, and not dissolved in the water. A 
portion probably forms chemical combinations with other sus- 
pended or dissolved matters, and is changed into compounds 
which may be volatile and pass off into the air, or form insoluble 
precipitates. 

The remainder is rendered less perceptible or imperceptible 
to chemical means by dilution. Every stream has sources of 
inflowing water — feeders — which increase its volume, and thus 
dilute any foreign admixture. 

In view of these facts, the theory of the self-purification 
of streams, as formerly held, can no longer be regarded as true. 
But it is unquestionably true that running-water does regain its 
purity if the inflow of sewage and other refuse is not excessive. 
It cannot be stated with confidence, however, when a stream, 
once polluted, becomes fit to use again. Moreover, as it is not 
possible, by any practicable chemical treatment or filtration on 
a large scale, to make a polluted water absolutely wholesome, it 
is safer not to use as a source of domestic supply a stream which 
is known to have been seriously contaminated by sewage matters 
or other impurities. 

The water from fresh- water lakes and ponds is generally to 
be preferred to river-water for domestic use. It is less liable to 
become turbid from time to time, and, except in the case of 
small ponds, inflow of sewage is not likely to cause fouling of 
the water to any serious extent. When the supply can be 
drawn from large lakes, as is done in Chicago and other cities 
on the great lakes of the United States, no purer or better source 
can be desired. In these cases the point whence the water is 
taken should be far enough from shore to avoid possibility of 
sewage contamination. When the water-supply is taken from 
small ponds, all sewage and waste products from houses and 
factories must be rigidly excluded ; otherwise, diseases attribu- 
table to the polluted water are likely to arise among those using 
the same. 

The water in small lakes and storage reservoirs sometimes 



56 TEXT-BOOK OF HYGIENE. 

becomes offensive in taste and odor. The water-supplies of 
several of the large Eastern cities have within the past seven or 
eight years at times had a peculiar odor and taste somewhat 
resembling cucumbers. After considerable study, Prof. Ira 
Remsen, of Baltimore, found the cause of this odor and taste 
in a minute fresh- water sponge, the Spongilla fluviatilis. A still 
more offensive odor, tersely described as the " pig-pen odor," is 
given to the water by the decay of certain species of nostoc and 
other algae. It is not known that either these vegetable or 
animal organisms, if present, render the water prejudicial to 
health. 

Ponds are often used as sources of ice-supply. It was 
formerly supposed that in the process of freezing, solid matters 
in the water were not included in the block of ice when con- 
gelation occurred. Recent observations have shown the falsity 
of this assumption. In 1875, an outbreak of acute intestinal 
disease at Rye Beach, New Hampshire, led to an inquiry by 
Dr. A. H. Nichols, which disclosed the fact that the ice used 
contained a large percentage of organic matter. 1 The use of 
ice from a different source was followed by an almost immediate 
disappearance of the disease. Upon further investigation it 
was discovered that the impure ice had been gathered from a 
small, stagnant pond into which a small brook carried large 
quantities of saw-dust from several saw-mills. The water of the 
pond was loaded with organic matter, and in summer the gases 
of decay arising from it were very offensive. Chemical exam- 
ination showed that the ice from this pond contained nearly 6 
parts of organic matter in 100,000, while in pure ice the organic 
matter amounted to only .3 part in 100,000. A similar inves- 
tigation into the character of the ice furnished to the residents 
of Newport, R. I., was made under the auspices of the Sanitary 
Protection Association of that city. The ice, which was cut 
from ponds in the immediate neighborhood of the city, was 
found to contain an excessive proportion of organic matter. 

1 Report Massachusetts State Board of Health, 1876, p. 467. 



SOURCES OF DRINKING-WATER. 57 

Large quantities of sewage and other impurities were discharged 
into these ponds. 1 

A series of experiments recently made by Dr. C. P. Pengra, 
of Michigan, shows 2 that the purification of the water by freezing 
is in no sense absolute. In experimenting with bacteria, infusoria, 
and other organisms, he found that from 9 to 11 per cent, re- 
mained in the ice and retained their vitality, so that when 
thawed they rapidly multiplied, and there was no apparent 
loss of numbers. In the ordinary process of freezing the upper 
portion is the purest, but if snow or rain fall upon the ice and 
freeze this upper layer will be found much more impure than 
the lower. Rational conclusions from these experiments are, 
that ice should not be gathered from an impure source, and that 
an early harvest of the ice should be encouraged. 

In a very recent research, Prudden has shown that typhoid 
bacilli contained in water are not entirely destroyed by freezing, 
even after remaining in this condition for 103 days. 

Springs and wells supply the water for most persons not 
aggregated in large communities, as cities and towns. Even in 
the latter no inconsiderable quantity of the water used for 
drinking and domestic purposes is derived from wells. Spring- 
water usually comes from a source at a considerable depth below 
the surface; that is to say, the water has percolated through 
thick strata of soil before re-appearing at the surface. In its 
passage through the soil it has lost most of its organic matter, 
and perhaps taken up mineral and gaseous constituents in larger 
quantities. It may be so strongly impregnated with the latter 
as to vitiate it for ordinary use and to render it valuable as a 
medicine. Ordinarily, however, spring-water is clear, cool, and 
sparkling, with a refreshing taste and uniform temperature, and 
is in all respects an agreeable and wholesome beverage. 

The character of well-water, on the contrary, is often justly 
open to grave suspicion. Being derived from those strata of the 

1 The Dangers of Impure Ice, in The Sanitarian, May, 1882. 

8 Private communication to the author. The memoir of Dr. Pengra has been published 
in the Report of the Michigan State Board of Health for 1884. 



58 TEXT-BOOK OF HYGIENE. 

soil which are most likely to be contaminated by the products 
of animal and vegetable decomposition, the wholesomeness of 
the water is inversely proportional to the degree of saturation of 
the soil with the products of decay. It has been found by 
experiment that, when organic matter largely diluted with water 
is allowed to percolate through soil, it undergoes a gradual 
decomposition in the presence of certain minute organisms, 
nitrates and nitrites being formed at the expense of the ammonia 
and other organic combinations. If, however, the soil is saturated 
with organic matter in excess, and in a state of concentration, 
putrefaction takes place, and the conversion of the organic 
matter into nitrates and nitrites is retarded. Hence, the drain- 
age of diluted sewage through a stratum of porous soil, not 
already saturated with putrefying matters, has no especially bad 
significance, even if the liquid should reach a well used as a 
source of drinking-water. It is probable that by the time the 
liquid portion of the sewage reached the well it would have 
arrived at that point when it could truthfully be termed pure 
water. At the same time it must be remembered that the puri- 
fying power of the soil cannot be relied upon if the supply of 
sewage or other animal or vegetable impurity is too abundant. 

Distillation is sometimes resorted to for the purpose of pro- 
curing drinking-water, especially at sea. Vessels now generally 
carry a still for this purpose. The principal objection to dis- 
tilled water is its insipidity, due to the absence of carbon dioxide 
and mineral constituents, which give to good drinking-water its 
savor. Distilled water may be aerated by passing it in fine 
streams through holes in the bottom of a cask, elevated so as to 
allow the water to pass through a considerable stratum of air. 
Lead is sometimes taken up from the distilling apparatus, and 
may cause lead poisoning in those using the water. 

Drinking-water is sometimes procured by melting snow or 
ice. It is not probable that water derived from these sources is 
unwholesome, although there is strong popular prejudice against 
it. Ice and snow may, however, contain large amounts of 



SOURCES OF DRINKING-WATER. 59 

impurities, as already referred to, 1 and be for this reason unfit 
for use. 

The following qualities are desirable in water for drinking 
and domestic purposes : — 

1. The water should be colorless, transparent, sufficiently 
aerated, of uniform temperature throughout the year, and with- 
out odor or decided taste. 

2. The mineral constituents (magnesium and lime salts) 
should not be present in greater proportion than 4 or 6 parts 
per 100,000. More than this gives to water that quality known 
as " hardness." 

3. There should be but little organic matter present, and 
no living or dead animal or vegetable organisms. 

4. The water should be entirely free from ammonia and 
nitrous acid, and should contain but very small quantities of 
nitrates, chlorides, and sulphates. 

5. It should contain less than one milligramme of lead per 
litre. A larger proportion is likely to be followed by lead 
poisoning. 

IMPURITIES IN WATER. 

The transparency and the color of water are affected by 
the presence of suspended or dissolved mineral or organic mat- 
ters. If, after standing for a time, the water deposits a sedi- 
ment, this is dependent upon insoluble matters. If the sediment 
turns black when heated in a porcelain capsule over an alcohol 
or gas flame it contains organic matter. If the sediment or 
residue effervesces upon the addition of hydrochloric acid the 
presence of carbonates is indicated. Water may be colored by 
metallic salts or by vegetable matter. It may also contain large 
quantities of mineral or organic matter, or even living organ- 
isms, without perceptibly diminishing its transparency. For 
example, the ova of tape-worms may exist in water in consider- 
able numbers, and yet remain perfectly invisible except under 
the microscope. 

1 See pages 52 and 53. 



60 TEXT-BOOK OF HYGIENE. 

The presence of sulphur compounds, or of various vege- 
table and animal organisms (sponges, algae, etc. 1 ), may give to 
water an unpleasant odor and taste. In the oil regions of this 
country most of the drinking-water is contaminated with petro- 
leum, which is very disagreeable to one unaccustomed to it. It 
is not probable that the small quantities of the oil imbibed with 
the water have any deleterious influence upon the organism. 

Many works on hygiene fix a limit to the amount of solid 
matter allowable in drinking-water. The International Con- 
gress of Hygiene, at Brussels, fixed the limit at 50 parts in 
100,000. It is impossible, however, to say of any particular 
specimen of water that its content of solid matter, whether or- 
ganic or mineral, will be prejudicial to health without trial. At 
the same time it is prudent to reject all waters containing a con- 
siderable proportion of solid organic matter, as determined by 
the degree of blackening on heating the sediment or residue 
after evaporation. 

The hardness of water is due to the presence of earthy car- 
bonates, or sulphates, or both. If the hardness is due to car- 
bonates it is dissipated by heat, as in boiling the water ; the 
carbon dioxide is driven off, and the base (calcium or magnesium 
oxide) is precipitated upon the bottom and sides of the vessel. 
This is termed the "removable hardness." The hardness due 
to the presence of earthy sulphates is not removed upon heating 
the water, and is termed the "permanent hardness." The hard- 
ness depending upon both the carbonates and sulphates is called 
the "total hardness." 

The proportion of the above-mentioned earthy salts present 
in a given specimen of water is determined by what is called the 
soap test. This test depends upon the property which lime and 
magnesia salts possess of decomposing soap (oleate and stearate 
of soda). The quantity of a solution of soap of a definite com- 
position decomposed by a quantity of hard water indicates the 
amount of the salts present. In this country and England this 

1 See page 52. 



IMPURITIES IN WATER. 61 

is generally expressed in degrees of Clark's scale, which are 
equivalent to grains of carbonate of lime per imperial gallon. 
Thus, if the chemist says that a certain sample of water has a 
total hardness of 16 degrees he means that the earthy salts in the 
sample decompose the same quantity of soap that would be de- 
composed by 16 grains of carbonate of lime per imperial gallon. 
In Germany each degree of the scale used expresses the soap 
decomposed by 1 part of calcium oxide per 100,000. In the 
scale used in France each degree corresponds to 1 part of car- 
bonate of lime in 100,000. So much of the hardness of water 
as is due to carbonates can be dissipated by boiling, which drives 
off the free carbon dioxide and allows the insoluble oxides to 
be deposited as an incrustation upon the bottom and sides of 
the vessel. 

The standard soap solution for testing the hardness of 
water is made as follows : Dissolve 10 grammes of Castile soap 
in a litre of weak (35 per cent.) alcohol. One cubic centimetre 
of this solution precipitates 1 milligramme of carbonate of lime. 
The test is made as follows : To a definitely-measured quantity 
of water (say 100 cubic centimetres) in a graduated burette a 
quantity of the soap solution is added and the mixture shaken 
up; so long as there are dissolved lime or magnesium salts in 
the water the soap is decomposed and no lather is formed. Soap 
solution is now added gradually and the shaking repeated until 
there is evidence of saponification by the formation of a more or 
less permanent lather or froth. The quantity of soap solution 
used is noted, and the test is repeated. The mean of the quan- 
tity of soap solution in cubic centimetres used in the two ex- 
periments will represent approximately the proportion of salts in 
grains of carbonate of lime per gallon present, or, as it is gen- 
erally expressed, in "degrees of hardness." 

The scale on the following page shows the quantity of 
soap solution required to decompose the proportion of calcium 
oxide per 100,000/ 

1 Uffelmann, Handbuch der Hygiene, p. 94. 



62 TEXT-BOOK OF HYGIENE. 













Table 


IV. 










1 


part 


CaO 


per 


100,000 water 


requires 5.4 


c.cm. 


standard 


soap s 


olu 


2 


parts 


u 


a 


a 


a 


u 


9.4 


a 


a 


u 


u 


3 


u 


a 


a 


u 


u 


it, 


13.2 


a 


tt 


(( 


u 


4 


tt 


u 


it 


a 


(i 


a 


n.o 


a 


u 


u 


It 


5 


tt 


it 


a 


a 


u 


tt 


20.8 


a 


tt 


It 


u 


6 


u 


tt 


K 


(( 


u 


it 


24.4 


(i 


a 


It 


it 


6.5 


tt 


u 


a 


a 


u 


a 


26.2 


« 


a 


a 


tt 


T.O 


a 


a 


a 


a 


(1 


u 


28.0 


a 


tt 


u 


il 


T.5 


a 


a 


a 


a 


a 


tt 


29.8 


a 


it 


a 


u 


8.0 


tt 


a 


a 


a 


a 


tt 


31.6 


a 


it 


tt 


It 


8.5 


tt 


tt 


a 


a 


a 


tt 


33.3 


tt 


tt 


« 


a 


9.0 


u 


a 


u 


u 


u 


a 


35.0 


tt 


tt 


u 


u 


9.5 


a 


it 


t( 


u 


a 


tt 


36.T 


a 


tt 


u 


a 


10.0 


tt 


tt 


u 


a 


u 


a 


38.4 


u 


a 


u 


a 


10.5 


a 


a 


it 


a 


a 


a 


40.1 


tt 


a 


li 


tt 


11.0 


a 


tt 


a 


a 


a 


a 


41.8 


tt 


a 


u 


it 


11.5 


a 


u 


u 


a 


u 


tt 


43.4 


a 


a 


u 


tt 


12.0 


a 


u 


tt 


u 


u 


it 


45.0 


tt 


tt 


tt 


u 



If there are more than 12 parts of lime in 100,000 the 
water is diluted with an equal proportion of distilled water and 
the resultant multiplied by two. 

Mr. Wynter Blyth has proposed to take the total residue 
as representing approximately the total hardness of the water, 
but Dr. Fox points out that there may be a large excess of in- 
organic solids present in water that is quite soft and originally 
pure. 

Hard water is objectionable for domestic use, as it is waste- 
ful of soap. In cooking certain vegetables, such as peas and 
beans, the hulls are not thoroughly softened. In making infu- 
sions of tea and coffee, larger quantities of these materials are 
needed than where soft water is used. 

DISEASES DUE TO IMPURE DRINKING-WATER. 

Hard water is popularly believed to be the cause of calcu- 
lous diseases, and of goitre and cretinism, but no reliable obser- 
vations are on record showing that the belief is founded upon 



DISEASES DUE TO IMPURE DRINKING- WATER. 63 

fact. At the same time it is undoubtedly true that calcareous 
waters produce gastric and intestinal derangements in those 
unaccustomed to their use. 

Large amounts of suspended mineral matter are frequently 
present in river-water, and may give rise to derangements of the 
digestive organs. If there is carbonate of lime present, the 
water can be easily clarified by the addition of a small quantity 
of alum. Sulphate of lime and a bulky precipitate of hydrate 
of alumina are formed, which carry the suspended matters to 
the bottom. About 10 centigrammes of crystallized alum are 
sufficient to clarify a litre of water. This amount of alum is 
too small to affect the taste of the water perceptibly. This 
method is frequently used to clarify and render fit for use the 
water of the Mississippi River, which is usually very muddy. 
Dr. Parkes quotes the following striking instance of the prac- 
tical value of clarifying muddy water by means of alum. 1 In 
1868 the right wing of the Ninety-second Regiment of High- 
landers, going up the river Indus, suffered from diarrhoea from 
the use of the water, which was very muddy. The left wing 
of the same regiment used water from the same source, but pre- 
cipitated the suspended matters with alum and had no diarrhoea. 
The right wing then adopted the same plan with like success. 
Although the opinion is widespread that water containing much 
mineral matter, either in solution or in suspension, is deleterious 
to health, there is very little evidence absolutely trustworthy 
upon this point. 

The presence of large quantities of organic matter in water, 
whether these matters be of animal or vegetable origin, must 
always be looked upon with suspicion. The observation was 
made by Hippocrates twenty-three centuries ago, that persons 
using the water from marshes, i.e., water containing vegetable 
matter, suffer from enlarged spleens. Many physicians, both of 
ancient and modern times, seem to have held this opinion, but 
the first positive observation in medical literature is the now 

1 Manual of Practical Hygiene, 6th ed., Xew York, vol i, p. 341. 



64 TEXT-BOOK OF HYGIENE. 

classical one of the ship Argo, reported by Boudin. 1 In 1834 
the transport Argo, in company with two other vessels, carried 
800 soldiers from Bona, in Algiers, to Marseilles. The troops 
were all in good health when they left Algiers. All three of 
the vessels arrived in Marseilles on the same day. In two of them 
there were 680 men, not one of whom was sick. Out of the 
remaining 120 men who were on the third vessel, the Argo, 13 
died during the passage, and 98 of the 107 survivors suffered 
from paludal fevers of all forms. None of the crew of the 
Argo were sick, however. The two vessels exempt from sick- 
ness, and the crew of the Argo, had been supplied with pure 
water, while the soldiers on the latter vessel had been furnished 
with water from a marsh. This water was said to have a dis- 
agreeable odor and taste. The testimony of a large number of 
East India physicians is also quoted by Parkes in support of 
the view that malarial fevers are often caused by impure drink- 
ing-water. The observations of Dr. Charles Smart, upon the 
production of "mountain fever" of the Western territories, 
have already been referred to. The author ventures to state it 
as his opinion, however, that the instances in which malarial 
fevers are due to impure drinking-water are very rare. 

The causation of typhoid fever and cholera by impure 
drinking-water will be presently referred to. Recently the 
opinion has been expressed by some that yellow fever and diph- 
theria are also spread by polluted drinking-water, but no strong 
evidence has yet been adduced in its support. 

There can be very little doubt that diarrhoea and dysentery 
are frequently caused by water which has been contaminated 
with decaying organic matter. The evidence in favor of this 
amounts practically to demonstration. 

It must not be forgotten that the ova of certain animal 
parasites, such as distoma hematobium, filaria sanguinis hominis, 
and medinensis, anchylostoma duodenale, and possibly of round- 

1 Quoted in Parkes, op. cit., p. 48 ; Nowak, Lehrbuch der Hygiene, p. 51 ; and in 
numerous other publications on Hygiene. 



DISEASES DUE TO IMPURE DRINKING-WATER. 65 

and tape- worms, for example, are taken into the system along 
with the drinking-water. 

Organic detritus of various kinds, sewage, decomposing 
animal and vegetable matter, refuse from manufacturing estab- 
lishments, may be a source of pollution of water and render it 
unfit for drinking or other domestic purposes. It is, however, 
not certain that water thus rendered unclean is prejudicial to 
health; in fact, Dr. Emmerich, of Munich, has recently put his 
skepticism on this point to a practical test. For two weeks he 
drank daily from half a litre to a litre of very filthy water; in 
fact, nothing less than sewage. The water was both chemically 
and physically exceedingly impure. Several of the experi- 
menter's patients partook of the same water without any ill 
effect. He even claims that a gastric catarrh, from which he 
was suffering when the experiment was begun, was improved 
during its course. 1 

The results of Emmerich's experiments, and of other well- 
known observations, seem almost conclusive that the products of 
animal and vegetable decomposition, taken into the body with 
the drinking-water, cannot be looked upon as certainly harmful. 
Should, however, water containing such impurities, or even 
water apparently pure, contain the germs of one of the specific 
diseases, — cholera, typhoid fever, or, perhaps, yellow, malarial, 
or scarlet fevers, or diphtheria, — it is probable that such diseases 
would be communicated to the consumer of the water. 

Many instances are on record where outbreaks of typhoid 
fever have been clearly attributable to pollution of the drinking- 
water by the germ of the disease from a previous case. 

One of the most remarkable of these outbreaks is that re- 
corded by Dr. Thorne. 2 About the end of January, 1879, 
typhoid fever began suddenly in the adjoining towns of Cater- 
ham and Red Hill. Within six weeks 352 cases occurred. All 

1 "Wolffhuegel : Wasserversorgung, in Pettenkof er u. Ziemssen's Handbuch der Hygiene, 
I Abth., II Hlfte, p. 97. 

2 Report of the medical officer to the Local Government Board for 1879. Quoted in Fo- 
dor : Hygienische Untersuchungen, etc., H Abth., p. 261. 



66 TEXT-BOOK OF HYGIENE. 

other sources of the disease were excluded except the drinking- 
water, to pollution of which it was traced with almost absolute 
certainty. Caterham contained 558 houses and Red Hill 1700. 
Of the former 419 and of the latter 924 drew their drinking- 
water from a common supply, having its source in a well several 
hundred feet deep. The insane asylum, with 2000 inmates, and 
the military barracks in Caterham used water from a private 
well. There was no typhoid fever among the last two commu- 
nities. During January one of the workmen engaged in some 
excavation near the public well was taken ill with diarrhoea and 
fever, — probably typhoid, — but was still able to continue his 
work. His dejections were often voided where they were cer- 
tain to become mingled with the water of the common supply. 
This man's diarrhoea began on January 5th and continued until 
the 20th of the month, during which time he remained at work. 
On the latter date he was compelled to quit work and take to 
his bed. Exactly two weeks from the beginning of the man's 
sickness, on January 19th, the first case of typhoid occurred in 
Caterham, and then rapidly increased. The first case occurred, 
therefore, just fourteen days — the incubative period of typhoid 
— after the presumed infection of the drinking-water by the de- 
jections of the sick laborer, who had come from Croydon, where 
typhoid fever was at the time prevalent. Within two weeks 
from the appearance of the first case the epidemic had reached its 
height, and then rapidly declined, disappearing almost entirely in 
a month after the outbreak. It was shown by Dr. Thorne that 
nearly all the houses in which the disease appeared were sup- 
plied with water from the source above mentioned, while other 
houses in the immediate vicinity of the infected ones remained 
free from the disease. 

In 1874 there was an outbreak of typhoid fever in the 
town of Over Darwen, in which nearly 10 per cent, of the in- 
habitants were attacked. Here the source of the disease was 
also traced to an infected water-supply. 

Dr. Buchanan has shown that an outbreak among the stu- 



DISEASES DUE TO IMPURE DRINKING-WATER. 67 

dents of the University of Cambridge was likewise attributable 
to an infected water-supply. 

In this country the reports of the Boards of Health of the 
various States teem with accounts of localized outbreaks of 
typhoid fever, referred to infected or polluted drinking-water. 
In most instances the evidence furnished by the observers is not 
conclusive. In many, however, especially of those found in the 
Massachusetts and Michigan reports, the fact of the communi- 
cation of the disease in this manner seems unquestionable. One 
of these is as follows: Out of 40 families, all using water 
from a certain well, there occurred 23 cases of typhoid fever. 
Out of 47 families, living in the same neighborhood, but using 
water from different sources, only 2 had typhoid fever. 1 Dr. C. 
F. Folsom has published a very suggestive account of a house 
epidemic, 2 where 9 persons in a single house, who all drank water 
from a well which was proven to be infected from a privy, were 
attacked by this disease. 

In 1885 an epidemic of typhoid fever began in Plymouth, 
a mining town of 8000 or 9000 inhabitants, situated in the 
Wyoming coal region of Pennsylvania, and on the right bank 
of the Susquehanna River. The epidemic began in April, and 
lasted until the ensuing September. There were 1104 persons 
attacked by the disease, of which number 114, or 10.3 per cent., 
died. The careful inspection made into the history of this 
epidemic revealed the fact that the public water-supply had 
unquestionably become polluted by the faecal discharges of 
typhoid-fever patients, and the entire course of the disease, in 
this instance, is in complete accord with the view that the origin 
and spread of the epidemic were due to the pollution of the 
drinking-water with the typhoid-fever poison. 

In addition, Chantemesse and Vidal have demonstrated the 
presence of the bacillus of Eberth, which is now generally rec- 
ognized as the cause of typhoid fever, in drinking-water from 

1 Transactions Mich. Med. Society, p. 401, 1883. 

* Boston Med. and Surg. Journal, vol. cii, pp. 227, 261. 



68 TEXT-BOOK OF HYGIENE. 

a well near Paris, to which a small outbreak of typhoid had 
been traced. This demonstration has also been furnished by 
Prof. V. C. Vaughan, in connection with an outbreak of the 
same disease in the State of Michigan. 

The numerous cases of typhoid fever which have been 
attributed to the use of infected milk may be included in this 
category. It is probable that the milk became infected either 
through polluted water used for the purpose of cleansing the 
milk-vessels or in diluting the milk. Mr. Ernest Hart has re- 
corded 1 50 epidemics of typhoid fever, 15 of scarlet fever, and 
7 of diphtheria, the cause of which he has attributed to infected 
milk. 

It is probable that typhoid fever is, in the majority of cases, 
spread through the medium of polluted drinking-water, and, in 
many of the instances on record, the relations between cause 
and effect — impure water and typhoid fever — have been so clearly 
made out as to no longer permit any doubt upon the question. 

As it is with typhoid fever, so also with cholera. In a later 
chapter the origin and propagation of typhoid fever and cholera 
will be discussed more fully. At the present time only the rela- 
tions of the drinking-water to the spread of these diseases can 
be considered. In the instance to be presently noted the con- 
nection between the infected water, on one hand, and the out- 
break of cholera, on the other, is so clearly shown as to be 
almost equivalent to a mathematical demonstration. The facts 
in the case were brought to light after a patient inquiry by a 
commission, whose report drawn up by Mr. John Marshall has 
made the occurrence classical. In 1854 the people of a well-to- 
do and otherwise healthy district in the eastern part of London 
suffered severely from cholera. Upon inquiry the fact was 
elicited that a child had died of cholera at No. 40 Broad Street, 
and that its excreta had been emptied into a cess-pool situated 
only three feet from the well of a public pump in that street, 
from which most of the neighboring people took their drinking- 

1 Transactions Seventh Int. Med. Congress, vol. iv, p. 391, 1881. 



DISEASES DUE TO IMPURE DRINKING-WATER. 69 

water. It was further discovered that the bricks of the cess- 
pool wall were loose and permitted its contents to drain into 
the pump-well. (It should be noted that the communication 
between the cess-pool and well was direct ; that there was im- 
mediate drainage, not percolation through the soil.) In one 
day 140 to 150 people were attacked, and it was found that 
nearly all the persons who had the malady during the first few 
days of the outbreak drank the water from the pump. "When 
the pump was closed to public use by the authorities the epi- 
demic subsided. The most singular case connected with this 
outbreak was the following : In West End, Hampstead, several 
miles away from Broad Street, there occurred a fatal case of 
cholera in a woman 59 years old. This woman formerly lived 
in Broad Street, but had not been there for many months. A 
cart, however, went daily from Broad Street to West End, 
carrying, among other things, a large bottle of water from the 
pump referred to. The old lady preferred this water to all 
others, and secured a daily supply in the manner stated. A 
niece, who was on a visit to the old lady, drank of the same 
water. She returned to her home, in a high and healthy part 
of Islington, was likewise attacked by cholera and died. There 
were, at this time, no other cases of cholera at West End, nor in 
the neighborhood of these last two persons attacked. 

Most of the English medical officers in India hold strongly 
to the view that cholera is spread by polluted drinking-water, 
and the evidence in its favor is very strong. 

Quite recently (in 1885) Dr. Robert Koch discovered the 
cholera spirillum in a water-tank in Calcutta, used as a source 
of domestic supply, and in this way furnished another link in 
the chain of evidence connecting the spirillum, the drinking- 
water, and the outbreak of the disease. 

The evidence in favor of the influence of impure drinking- 
water on the causation of other diseases than those mentioned 
is not sufficient to justify any conclusions at present. 

The source of a water-supply may be pure, yet pollution 



70 TEXT-BOOK OF HYGIENE. 

may occur before the water is used by the persons to whom 
it is distributed. Supply-pipes may become defective, and the 
water become contaminated with sewage or other deleterious 
substances. It is a current belief that no impurity can gain 
access to hydrant-pipes between the reservoir, or source of 
supply, and the point of discharge of the water. Nevertheless, 
such contamination may occur very readily. The author and 
his colleague, Dr. J. W. Chambers, of Baltimore, proved this 
conclusively a few years ago by establishing an undoubted con- 
nection between a house-epidemic of typhoid fever and a defect 
in the hydrant supplying the family with water. 1 The hydrant 
was one of the class known as Clark's patent non-freezing 
hydrant. The mechanism of these hydrants is as follows : At 
the lower end of the vertical discharge-pipe is a glazed earthen- 
ware plunger, which works through a ring of rubber packing 
into a vacuum chamber. At the bottom of the vacuum chamber 
is a valve regulating the entrance of the water from the con- 
ducting-pipe. When the water is shut off this valve is kept 
closed by a spiral spring. When the crank of the hydrant is 
turned forward — that is, when the water is "turned on" — the 
plunger is forced to the bottom of the vacuum chamber, presses 
on the spring, opens the valve, and allows the water to dis- 
charge. When the crank is turned back the plunger is raised, 
releases the spiral spring, which forces the valve into its bed, and 
shuts off the water. The partial vacuum produced by the 
raising of the plunger draws the water, which is in the vertical 
discharge-pipe, into the vacuum chamber, which is so far below 
the surface as to be unaffected by frost. In course of time, 
and with use, the rubber packing gets worn and permits gradual 
leakage into the vacuum chamber of the dirty stagnant water 
by which this part of the hydrant is always surrounded. Out- 
breaks of typhoid fever having a similar origin, 2 in which the 

1 On Preventable Pollution of Hydrant-Water and its Relation to the Spread of Ty. 
phoid Fever. Maryland Med. Journal, vol. vii, p. 271. 

2 Local Causes of Insanitation in Baltimore, by John Morris, M.D. Report Md. State 
Board of Health, 1878. 



DISEASES DUE TO IMPURE DRINKING-WATER. 71 

connection between cause and effect was clearly shown, have 
been reported by other physicians of the same city. 

Aside from the practical question of the causation of disease 
by polluted water, a more abstract and aesthetic idea is involved 
in consciously taking any impurity into the system. The in- 
stincts of man, as well as of most animals, revolt at it. These 
inborn instincts, which constitute the sanitary conscience, as 
Soyka says, demand purity of food and water, as they insist on 
cleanliness of the body, of clothing, and of the dwelling. 

STORAGE AND PURIFICATION OF WATER. 

Wherever a large supply of water is needed, unless drawn 
direct from a well or spring, or pumped directly from its source, 
arrangements for storage are necessary. Cisterns and large 
reservoirs are made use of for this purpose. River-water, espe- 
cially, requires a period of rest in a storage reservoir in order to 
allow deposition of the large amount of suspended matter in it. 
Prolonged storage also gives opportunity for the conversion of 
possibly deleterious organic compounds into simple and perhaps 
harmless combinations. Usually, in an elaborate system of 
water-works, a series of reservoirs is built, in which the water is 
stored successively, so that before its final distribution through 
the street-mains it has become quite clear and pure. Filtration 
on a large scale is also used in connection with storage reservoirs 
in order to secure greater purity of the water. 

In the distribution of water, care should be taken that nothing 
deleterious is taken up by the water in its passage through the 
pipes. Lead poisoning is not infrequent from drinking-water that 
has passed through a long reach of lead pipe, or which has been 
standing in a vessel lined with lead. Tanks and storage cisterns 
should therefore not be lined with lead, and the use of lead pipe 
in the supply service should be avoided as much as possible. 
Fortunately, most natural waters possess a considerable propor- 
tion of carbon dioxide, which forms with the lead an almost 
insoluble carbonate of lead. This carbonate of lead is deposited 



72 TEXT-BOOK OF HYGIENE. 

on the inside of the pipes, and protects both the pipes against 
erosive action from other constituents of the water, and also 
prevents the contamination of the water by the lead. An excess 
of carbon dioxide in the water renders this deposit soluble, and 
may cause serious poisoning. Any water which is shown by 
analysis to contain over 1 milligramme of lead per 100,000 is 
dangerous, and should be rejected. 

Owing to the possibility of defilement of the water from 
improper construction of hydrants, all outdoor hydrants should 
be discouraged as much as possible, and should be replaced by a 
simple tap-cock indoors. The pipes should also be laid deep 
enough under-ground, or otherwise protected against freezing in 
winter. 

A number of methods, all more or less efficient, have been 
introduced to purify water when it needs purification before 
being fit for use. These methods either comprise filtration or 
seek to purify the water without the aid of this process. One 
of the methods of purification without filtration consists in 
exposing the water to the air in small streams. This was pro- 
posed by Lind more than a century ago, and has since been 
frequently revived. The water is passed through a sieve, or a 
perforated tin or wooden plate, so as to cause it to fall for a 
distance through the air in finely-divided currents. By this 
process sulphuretted hydrogen, offensive organic vapors, and 
possibly dissolved organic matters are removed. This process 
has been used in Russia on a large scale. 

By boiling and agitation, carbonate of lime, sulphuretted 
hydrogen, and organic matter are removed or rendered innocuous. 
Vegetable germs are usually destroyed, although Tyndall has 
shown that some bacterial germs withstand a temperature higher 
than that of boiling water. Pathogenic germs are, however, all 
destroyed by boiling water acting upon them for ten minutes, as 
shown by Dr. G. M. Sternberg. 1 

As has already been mentioned, 2 alum is one of the readiest 

1 Report of Committee on Disinfectants, 1888. 2 See page 59. 



STORAGE AND PURIFICATION OF WATER. 73 

and most efficient means of removing suspended matters from 
water. 

Permanganate of potassium is sometimes used to purify 
water containing considerable organic matter. The perman- 
ganate rapidly oxidizes the organic matter, and is believed to 
render it harmless. There is no certainty, however, that the 
germs of specific diseases are destroyed by the action of this 
salt, in the proportion in which it could be used for the purposes 
of water purification. 

A yellow tint is given to the water by the permanganate, 
which is due to finely-divided peroxide of manganese. This 
does no harm, but is unpleasant. 

Water unfitted for use by organic matter is sometimes 
rendered usable by infusing certain vegetable astringents in it. 
Thus, it is said that in certain parts of China, where the water 
contains large quantities of organic matter, the inhabitants drink 
water only in the form of tea. The tannin of the tea-leaves 
precipitates the suspended matters and renders the water fit for 
use. Mixing the water with red wine, which is astringent, has 
the same effect. 1 

Filtration is an efficient means of removing suspended 
matters. Charcoal, sand, gravel, and spongy iron are used as 
filtering material. A most economical filter is one made of fine, 
clean sand, above which layers of gravel of a gradually-increasing 
size are placed. The coarser particles of suspended matter are 
arrested before the sand, which removes most of the coloring 
and organic matters, is reached. 

Filters easily become fouled by the matters arrested in the 
interstices of the filtering material, and hence require frequent 
renewal or cleansing. A cheap and efficient filter is made by 
placing a sheet of druggists' filtering-paper in a glass funnel 
and filtering the water through it. A new and clean sheet of 
paper should be used every day. 

M. Chamberland has invented a filter which is said to be 

1 Champouillon, quoted in Med. and Surg. Hist, of the War, part ii med. vol., p. 613. 



74 TEXT-BOOK OF HYGIENE. 

absolutely germ-proof, but this power is not permanent, as after 
a week micro-organisms pass through the filtering material. 
The same is true of all other filters hitherto invented. 



TESTS FOR IMPURITIES IN WATER. 

Accurate and reliable quantitative analyses of water can 
only be made by chemists of experience. Every intelligent 
person should, however, know how to determine the presence or 
absence of suspected impurities. The following methods are 
simple, and easily carried out: — 

The color, transparency, and odor of water are determined 
by the unaided senses. As a standard for comparison in making 
the color test, pure, distilled water may be used. Two tubes of 
clear, white glass, 61 centimetres long, are filled with distilled 
water and with the specimen to be tested, and placed side by side 
upon a sheet of white paper. The tops of the tubes are covered 
with little squares of clear glass. The color is noted by com- 
paring the tints of the water in the two tubes. The same 
procedure may be used to determine the transparency of the 
water. 

While the color and turbidity show impurities, these are 
not necessarily prejudicial to health; on the other hand, the 
clearest and most sparkling water may contain so mnch poisonous 
matter as to be positively dangerous. The odor of the water is 
best ascertained by heating a small quantity in a narrow-necked 
flask to 40° to 45° C. (104° to 113° F.), and then taking a few 
strong whiffs at the flask. The odor may or may not indicate 
the presence of deleterious substances. 

The chemical examination of a water for sanitary purposes, 
short of a complete analysis, comprises the determination of the 
presence or absence of suspected impurities; in other words, it 
may be termed a qualitative analysis. In some cases an approxi- 
mate quantitative examination may also be made Avith little 
more trouble and skill. 



TESTS FOR IMPURITIES IN WATER. 75 

The examination may be divided into the following pro- 
cedures : — 

1. The determination of the total residue. 

2. The determination of the presence of — 

(a) Organic matter. 
(6) Chlorides. 

(c) Nitrogen compounds. 

(d) Mineral poisons. 

Determination of Total Solids. — Examination of the public 
water-supply of eight large cities in the United States shows 
that the total solid residue varies from 6 to 16 parts in 100,000. 
The total solids of a good drinking-water should not exceed 
25 to 30 parts per 100,000, although a larger quantity may be 
present without being harmful. The method of determining 
the total solids is to evaporate a definite quantity — say, 70 cubic 
centimetres of the water — in a previously-weighed platinum 
dish to dryness over a water-bath. The dish is then wiped dry 
and weighed again. The difference in weight between the 
empty dish and the latter with the dry residue represents the 
proportion of the latter in grains per gallon. To convert this 
figure into parts per 100,000 the number of grains per gallon 
is divided by .7. For example, if the number of grains of solid 
residue in the specimen examined is 22 A, then 

22.4 -=- .7 = 32 parts per 100,000. 

Determination of Organic Matter. — This is the most difficult 
test to apply in the sanitary examination of water. While it is 
comparatively easy to determine the presence of organic matter, 
its quantity and nature are exceedingly complex problems to 
solve. 

The presence of organic impurity in water may be detected 
by the permanganate-of-potash test, the nitrate-of-silver test, 
and the incineration test. Neither of these processes is compe- 
tent to differentiate noxious from inoffensive organic matter. 
The permanganate test, modified by Dr. DeChaumont, is the 



76 TEXT-BOOK OF HYGIENE. 

one usually adopted. The process is as follows: To 250 cubic 
centimetres of the water to be examined add 5 cubic centimetres 
of dilute sulphuric acid (10 per cent.) in a clear, white glass 
flask. Then add permanganate of potassium solution (395 
milligrammes to 1 litre of distilled water) until the water has 
taken a pink tinge. Heat the water to 140° F. (60° C), adding 
permanganate solution if the color disappears. When the tem- 
perature above mentioned is reached remove the flask from the 
burner, and add permanganate drop by drop until a faint pink 
color is obtained, which remains permanent for ten minutes. 
Read ofT the number of cubic centimetres of the permanganate 
solution used as required for total oxidizable matter. As the 
solution of permanganate yields in presence of an acid 0.1 of a 
milligramme of oxygen for each cubic centimetre, it is evident that 
the number of cubic centimetres of solution decomposed has 
furnished an equal number of tenths of a milligramme of oxygen 
which has entered into other combinations. 

But, inasmuch as all the oxidizable matter in the water 
may not be organic, the inorganic oxidizable matter (nitrous 
acid) must be separated. This is done by first boiling the water 
with sulphuric acid, as above (250 cubic centimetres -f- 5 cubic 
centimetres), for twenty minutes, to remove the nitrous acid. 
Then allow the acidulated water to cool down to 60 degrees 
and add the permanganate until a pink color is obtained for ten 
minutes. The amount of permanganate solution used gives the 
number of milligrammes of oxygen required for oxidizable 
organic matter. 

Determination of Chlorides. — Chlorine, or its compounds, 
when present in drinking-water, represent generally sewage 
pollution. It is true that chlorine may be in excess in water, 
and the latter, nevertheless, be entirely free from sewage or 
urine, but this occurs only where there is a natural deposit of 
chlorine compounds in the soil from which the supply is drawn. 
If communication with the sea or salt-deposits is excluded, the 
chlorine may be assumed to be due to the inflow of sewage. 



TESTS FOR IMPURITIES IN WATER. 77 

Especially is this the case if the test for organic matter has given 
positive results. The proportion of chlorine may be estimated 
thus: Place 70 cubic centimetres of the water into an evapo- 
rating dish, and add a small fragment of neutral chromate of 
potash. Then, by means of a pipette graduated to tenths of a 
cubic centimetre, standard solution of nitrate of silver 1 should 
be allowed to drop into the water until the red color produced 
remains permanent. The number of cubic centimetres of the 
silver solution required to produce the permanent red tint is 
equivalent to the number of grains of chlorine per gallon, which, 
if divided by .7, gives the parts per 100,000. 

Another method of determining the presence of chlorine or 
chlorides is as follows: Acidulate about 16 cubic centimetres of 
the water to be tested with pure nitric acid, and add a few drops 
of a solution of nitrate of silver (1.5 grammes to 32 cubic cen- 
timetres of distilled water). A white precipitate, gradually 
changing to gray, is produced if chlorides are present. The 
degree of cloudiness produced will indicate approximately the 
amount of chlorides : Ci 1 .5 parts of chlorine per 100,000 give 
a haze; 5.7 parts per 100,000 give a marked turbidity; 14 parts 
per 100,000, considerable precipitate." If the chlorine is found 
by this test to exceed 1.5 parts per 100,000, the source of the 
contamination should be searched for. If drainage from a cess- 
pool is suspected, a quantity of salt water may be thrown into 
it, and the water again tested after an interval of four hours to 
see whether the chlorine has increased. 

Determination of Nitrites and Nitrates. — The presence of 
these nitrogen compounds in drinking-water should excite sus- 
picion of sewage contamination. They are the resultants of 
oxidation of nitrogenous organic matter, and, although water 
containing them is not necessarily dangerous, their presence 
should render a thorough examination of the source of supply 
imperative. 

1 Standard Solution of Nitrate of Silver.— Dissolve 4.79 grammes of crystallized nitrate 
of silver in 1 litre of distilled water. One cubic centimetre of this solution precipitates 1 milli- 
gramme of chlorine. 



78 TEXT-BOOK OF HYGIENE. 

The readiest method of detecting nitrates and nitrites in 
water is by the pyrogallol test. This may be performed as fol- 
lows : Put 2 cubic centimetres of pure sulphuric acid in a small 
test-tube and add 1 cubic centimetre of the water to be tested. 
To this mixture is added 1 drop of a solution of pyrogallol 
(65 centigrammes to 30 cubic centimetres) in distilled water, 
acidulated with 2 drops of sulphuric acid. The water becomes 
colored a dark amethyst or wine brown if the salts are present. 
The depth of color indicates approximately the amount of the 
impurity. 

The following test for nitric acid or nitrates may also be used : 
A small quantity of the water is evaporated to dryness, and a 
few drops of a solution of carbolic acid in 4 parts of con- 
centrated sulphuric acid and 2 parts of distilled water added 
to the residue. If nitric acid is present, a brownish-red color 
results, which turns green and then yellow upon the addition of 
ammonia. 

Nitrous acid or nitrites will give a reaction with iodide of 
potassium and starch ; 350 to 600 cubic centimetres of water 
in a flask are acidulated with a few drops of dilute sulphuric 
acid, and a little solution of iodide of potassium added. About 
2 grammes of freshly-prepared starch are added and the mixture 
shaken. If nitrous acid is present, the iodide is decomposed, 
setting free the iodine, which combines with the starch, causing 
a blue color. The test is a very delicate one. 

Ammonia. — The presence of this is determined by Nessler's 
reagent, 1 as follows : 100 cubic centimetres of the water to be 
examined is treated with 0.5 cubic centimetre of caustic soda 
solution and 1 cubic centimetre of carbonate of soda solution 
to precipitate the earthy salts. After the precipitate has sub- 
sided, 1 cubic centimetre of Nessler's reagent is added. If 
ammonia is present the water takes a yellowish tint. 

1 Nessler's Reagent— Dissolve by heating and stirring 35 grammes of potassium iodide 
and 13 grammes of mercuric chloride in 800cubic centimetres of distilled water. Addgraduallya 
cold aqueous saturated solution of mercuric chloride until the red color produced just begins 
to be permanent ; 160 grammes of solid caustic potash are then added to the mixture which is to 
be diluted with distilled water until it exactly measures one litre. 



TESTS FOR IMPURITIES IN WATER. 



79 



Determination of Mineral Poisons. — Of these the most 
important are lead, copper, zinc, and arsenic. The presence of 
any of these in even the smallest quantity is dangerous, and, if 
constant, the water so contaminated should not be used for 
drinking purposes. 

In order to detect lead 250 cubic centimetres of the water 
is first treated with hydrochloric acid, and then sulphuretted 
hydrogen (in aqueous solution) is added. If a brownish or 
black precipitate results, either lead or copper may be present. 

On filtering the water, dissolving the residue in hot, diluted 
nitric acid, and adding a solution of potassium bichromate, a 
yellow precipitate, soluble in caustic potash, is thrown down if 
lead is present. If the precipitate produced by sulphuretted 
hydrogen is dissolved, as above, and ammonia added, a blue 
color is produced in the presence of copper. To detect zinc the 
sulphuretted hydrogen precipitate is treated with caustic soda, 
again filtered, and sulphuretted hydrogen added to the filtering 
liquid. A white precipitate indicates the presence of zinc. 

Arsenic is detected by Marsh's test. Mr. A. J. Cooper has 

prepared the following table showing the accuracy of certain 

tests employed for the determination of poisonous metals in 

drinking-water : — 

Table Y. 



Metal. 


Reagent. 


Depth of Liquid, 3% 
Inches. 


Depth of Liquid, 14^ 

Inches (cylinder inclosed 

in opaque tube). 






1 part of metal detected in 


1 part of metal detected in 


Copper . . . 


K 4 Cy 6 Fe 


4,000,000 of water. 


11,750,000 of water. 


Copper 




NH 4 HO 


1,000.000 " 


1,950,000 " 


Copper 




BUS 


4,150,000 " 


15,660,000 " 


Zinc 




NH 4 HS 


2,500,000 " 




Arsenic 




H 2 S 


3,600,000 " 


7,520,000 " 


Lead . 




K 2 Cr0 4 


4,000,000 " 


5,875,000 " 


Lead . 




H 2 S 


100,000,000 " 


196,000,000 " 



In making the tests a tall glass is used, and the formation 
of the precipitate observed by looking down perpendicularly 
through the column of liquid of 3} inches (95 millimetres) and 
14J inches (368 millimetres) respectively. 



80 TEXT-BOOK OF HYGIENE. 



SIGNIFICATION OF THE VARIOUS IMPURITIES INDICATED BY THE 
FOREGOING TESTS. 

The following summary gives, briefly, the inferences that 
may be drawn from the result of the foregoing tests 1 : — 

"If chlorine be present inconsiderable quantity it either 
comes from strata containing chloride of sodium or calcium, 
from impregnation of sea-water, or from admixture of liquid 
excreta of men and animals. In the first case the water is 
often alkaline from sodium carbonate ; there is an absence, or 
nearly so, of oxidized organic matters, as indicated by nitric and 
nitrous acids and ammonia, and of organic matter; there is 
often much sulphuric acid. If it be from calcium chloride there 
is a large precipitate with ammonium oxalate after boiling. If 
the chlorine be from impregnation with sea-water, it is often in 
very large quantity ; there is much magnesia, and little evidence 
of oxidized products from organic matters. If from sewage the 
chlorine is marked, and there is coincident evidence of nitric and 
nitrous acids and ammonia, and if the contamination be recent 
of oxidizable organic matters. 

"Ammonia is almost always present in very small quan- 
tity, but if it be in large enough amount to be detected without 
distillation it is suspicious. If nitrates, etc., be also present, it 
is likely to be from animal substances, excreta, etc. Nitrates 
and nitrites indicate previously-existing organic matters, prob- 
ably animal, but nitrates may also arise from vegetable matter, 
although this is probably less usual. If nitrites largely exist it 
is generally supposed that the contamination is recent ; the co- 
incidence of easily-oxidized organic matters, of ammonia, and 
of chlorine in some quantity, would be in favor of an animal 
origin. If a water gives the test of nitric acid, but not of 
nitrous acid, and very little ammonia, either potassium, sodium, 
or calcium nitrate is present, derived from soil impregnated 
with animal substances at some anterior date. If nitrites are 

1 Parkes' Hygiene, vol. i, p. 79. 



SIGNIFICATION OF VARIOUS IMPURITIES. 81 

present at first, and after a few days disappear, this arises from 
continued oxidation into nitrates ; if nitrates disappear it seems 
probable this is caused by the action of bacteria or other low 
forms of life. Sometimes in such a case nitrites may be formed 
from the nitrates. Lime in large quantity indicates calcium car- 
bonate if boiling removes the lime, sulphate or chloride or ni- 
trate if boiling has little effect. Testing for calcium carbonate 
is important in connection with purification with alum. Sul- 
phuric acid in large quantity, with little lime, indicate sulphate 
of sodium, and usually much chloride and carbonate of sodium 
are also present, and on evaporation the water is alkaline. 
Large evidence of nitric acid, with little evidence of organic 
matter, indicates old contamination ; if the organic matter be 
large, and especially if there be nitrous acid as well as nitric 
present, the impregnation is recent." 

THE BIOLOGICAL OR BACTERIOLOGICAL EXAMINATION OF DRINKING- 
WATER. 

Since the development of the methods of cultivation of 
micro-organisms by Koch and his pupils, and their employment 
for the study of water pollution by Meade Bolton, Wolff hiigel 
and BAedel, Percy Frankland, Prudden, and others, and the un- 
satisfactory results of chemical analysis, some sanitarians have 
expressed the conviction that the biological method is the only 
exact one for determining water pollution from a sanitary point 
of view. While this may be conceded, it is also true that very 
few health officers are competent to give an expert opinion upon 
the nature of the organisms which may be found in the water 
examined. It requires but little technical skill to make cultiva- 
tions of bacteria from samples of water, but only an expert 
bacteriologist may safely pronounce upon the nature of the 
organisms constituting the various colonies which develop upon 
the nutritive gelatin. Just as the mere presence of organic 
matter as determined by. the chemist is not indicative of a dan- 
gerous quality in the water unless the kind of organic matter 



82 



TEXT-BOOK OF HYGIENE. 



and its derivation be also specified, so likewise the presence of 
bacteria alone is of small significance ; the danger consists not 
in bacteria, but in certain kinds of bacteria. The differential 
diagnosis is possible only to the trained bacteriologist. 

While, as stated, a positive decision as to the sanitary value 
of a water may often be impossible, there are certain chemical 
and microscopical features which stamp a water as good or bad. 
Dr. DeChaumont gives an approximate valuation which may 
often serve as a useful guide. 1 

He classifies water under the four heads of Pure and 
Wholesome Water, Usable Water, Suspicious Water, and Im- 
pure Water. The characters of these waters are arranged in a 
series of tables, the essential details of which are given in 
Table VI. 

Table VI. 





Pure 


Usable 


Suspicious • 


Impure 




Water. 


Water. 


Water. 


Water. 


Chemical 










Constituents. 












I. 


II. 


ni. 


IV. 




Parts in 100,000. 


Parts in 100,000. 


Parts in 100,000. 


Parts in 100,000. 


Chlorine in solution . 


Under 1.4000 


Under 4.2857 


4-7 


Above 7.1428 


Solids " total . 


" 7.1428 


" 42.8571 


43-71 


" 71.4285 


" " volatile 


" 1.4000 


" 4.2857 


4-7 


" 7.1428 


Ammonia, free or sa- 










line 


" 0.0020 


" 0.0050 


0.0050-0.0100 


" 0.0100 


Ammonia, albuminoid 


" 0.0050 


" 0.0100 


0.0100-0.0125 


" 0.0125 


Nitric acid in nitrates 


" 0.0323 


" 0.5000 


0.5-1.0 


" 1 0000 


" " nitrites 


Nil. 


Nil. 


0.0500 


" 0.0500 


Nitrogen in nitrates . 


" 0.0140 


" 0.1129 


0.1243-0.2373 


" 2415 


Total nitrogen . . . 


" 0.0230 


" 0.1252 


0.1255-0.2465 


" 0.2601 


Oxygen absorbed by- 










permanganate and 










acid within half an 










hour at 140° F. . . 


" 0.0250 


" 0.1000 


0.1000-0.1500 


" 0.1500. 


Total hardness . . . 


" 8.5 


" 17.3 


Above 17.0 


" 28.5 


Permanent hardness . 


<' 3.0 


" 5.7 


" 5.7 


" 8.7 


Phosphoric acid in 










phosphates . . . 


Traces. 


Traces. 


Heavy traces. 


Heavy traces. 


Sulphuric acid in sul- 










phates 


<< 


Under 3.000 


Above 3.000 


Above 4.2857 


Heavy metals . . . 


Nil. 


Traces. 


Traces. 


( Any except 
( iron. 
Present. 


Hydrogen sulphide . 


K 


Nil. 


Nil. 


Alkaline sulphides . 




<« 


<< 





• Parkes' Hygiene, vol. i, pp. 103-106. 



EXAMINATION OF DRINKING-WATER. 



83 



Physical Characters. 

No. I. Colorless, or bluish tint ; trans- 
parent, sparkling, and well aerated ; no 
sediment visible to naked eye ; no smell ; 
taste palatable. 

No. II. Colorless, or slightly greenish 
tint; transparent, sparkling, and well 
aerated ; no suspended matter, or else 
easily separated by coarse filtration or 
subsidence ; no smell ; taste palatable. 

No. III. Yellow, or strong, green 
color ; turbid ; suspended matter con- 
siderable ; no smell, but any marked 
taste. 

No. IV. Color, yellow or brown ; tur- 
bid, and not easily purified by coarse 
filtration ; large amount of suspended 
matter ; any marked smell or taste. 



Microscopical Characters. 

No. I. Mineral matter ; vegetable 
forms with endochrome ; large animal 
forms ; no organic debris. 

No. II. Same as No. I. 



No. III. Vegetable and animal forms 
more or less pale and colorless ; organic 
debris ; fibres of clothing, or other evi- 
dences of house-refuse. 

No. IV. Bacteria of any kind ; fungi ; 
numerous vegetable and animal forms 
of low types ; epithelia, or other animal 
structures ; evidences of sewage ; ova 
of parasites, etc. 



[The following works are recommended to those desiring 
fuller information upon the subjects embraced in the foregoing 
chapter : — 

Water Supply, by Wm. Ripley Nichols, N. Y., 1884.— A Guide to 
the Microscopic Examination of Drinking- Water, by J. D. MacPonald, 
R.N.F.R.S. — Sanitary Examinations of Water, Air, and Food, by Fox. — 
Report of the Committee on Water Pollution, Public Health, vol. xiv. 
Zeitschr. f. Hygiene, vol. i, by Bolton. — Prudden in N. Y. Medical 
Record, 1887. — Arb. aus d. Reichsgesundheitsamte, I, Wolffhiigel and 
Riedel. — Kenwood : The Hygienic Laboratoiy, Part I.] 



QUESTIONS TO CHAPTER II. 

Water. 

For what purposes do people need water? Why should the supply 
be pure? What is the quantity needed by each person daily, and what 
quantity should be supplied per head in towns and cities for all purposes ? 
How may waste of water be prevented ? What is the objection to the 
use of water-meters ? 

What is the original source of all fresh water ? How is rain-water 
usually collected and stored? What are the objections to underground 
cisterns? What is the only material of which underground cisterns 
should be made ? 

What impurities may rain-water contain ? Why is it so valuable for 
domestic purposes? What is the great objection to the use of rain- 
water ? 

From what source do most cities and towns derive their water- 
supply ? What precautions must be observed regarding such a source? 
What are some of the minor objections to the use of river-water? 
What peculiar diseases may be due to such water ? What is the most 
serious objection to the use of river-water for domestic purposes? 

How does a running stream purify itself? Can this self-purification 
be relied upon? Can it be stated definitely when a stream once polluted 
becomes fit for use again ? Is it safe to use water from a stream known 
to have been contaminated by sewage ? 

What is usually the quality of water from fresh-water lakes and 
ponds? What large city uses lake-water entirely? What precautions 
must be observed regarding such a source of supply? To what is the 
offensive taste and odor of water from small lakes or storage-reservoirs 
often due? 

Does water purify itself absolutely in freezing ? What matters may 
be found in ice? Are all pathogenic micro-organisms destroyed by 
freezing ? What part of ice is the purest? 

What class of persons usually derive their drinking-water from 
springs and wells? What is the relative purity of spring- and of well- 
water ? Why? What changes take place in diluted organic matter in 
percolating through the soil ? To what are these changes due ? What 
may retard or check these changes ? Is water containing nitrites and 

(84) 



QUESTIONS TO CHAPTER II. 85 

nitrates necessarily dangerous? Of what are nitrites and nitrates an 
indication ? 

What is the principal objection to the use of distilled water as a 
beverage, and how may this objection be overcome? What metallic 
poison may be taken up from the distilling apparatus ? 

Name some of the qualities that are desirable in water for drinking 
or domestic purposes. When is a water said to be hard ? 

What may affect the color and transparency of water ? Of what 
may the sediment in water be composed ? What impurities may there 
be in perfectly colorless and transparent water? How may the presence 
of sulphur compounds be detected ? What is the usual amount of solid 
matter permissible in water. What class of solid constituents especially 
should cause a water to be rejected ? 

To what is the hardness of water due? What is the distinction 
between " removable " or " temporary " and u permanent " hardness, 
and what is meant by " total " hardness ? How is the degree of hard- 
ness determined, and upon what does the test depend ? Describe the 
test. What is meant by Clark's scale ? Why is hard water objection- 
able for domestic use ? 

What diseases and derangements of health may be due to hard 
water? Is the evidence absolute regarding all of these? What troubles 
may large amounts of suspended mineral matter cause? How ma} r 
such water be clarified ? What mineral in the water is essential to the 
process ? 

What may be the effect of large quantities of organic matter in the 
water ? What infectious diseases may be due to impure drinking-water ? 
What other organisms harmful to health, other than bacteria, may be 
found in drinking-water? Name some notable places where epidemics 
have been undoubtedly caused by impure drinking-water. How may a 
milk-supply be infected by impure water ? How might a water be pol- 
luted in distribution, even though the source be pure? 

What is the advantage of a prolonged storage of river-water? 
What waters should not be stored in lead-lined cisterns or convej^ed in 
leaden pipes ? What is the greatest amount of lead permissible in water ? 

In what ways may water be purified on a large scale ? How majr the 
hardness of water be partially removed ? 

What methods may be used in the household for the purification of 
water? How may the water be softened ? How may disease germs and 
other organisms in water be destroj^ed ? How may organic matter be 
removed ? What are some good filtering materials ? What are some of 



86 QUESTIONS TO CHAPTER II. 

the essential requisites of a good house-filter? What is necessary that 
every house-filter may be safe for use? Are any filters absolutely germ- 
proof? 

How are the color, transparency, and odor of water determined, 
and what is the standard of comparison? Is a turbid or colored water 
necessarily harmful, and may a perfectly-clear water be dangerous to use? 

How are the total solids of a water determined quantitatively ? 
Describe the permanganate-of-potash test for the determination of the 
organic matter in water. What does an excess of chlorine or chlorides 
in water generally indicate, and why? How may these be determined 
quantitatively? If sewage contamination of a water be suspected, how 
may the suspicion be confirmed ? Why should the presence of nitrites or 
nitrates in water excite the suspicion of sewage contamination ? Give a 
test for each. By what reagent is the presence of ammonia determined ? 
How may the presence of lead, copper, zinc, or arsenic be detected? 

How ma}- we know whether an excess of chlorides is due to sewage 
contamination or not ? What is the probable source of ammonia if in 
excess and in company with nitrates, etc. ? Which is supposed to in- 
dicate the most recent contamination, nitrites or nitrates ? May nitrates 
arise from vegetable matters rather than animal ? What does the pres- 
ence of nitrates without nitrites or ammonia indicate ? What lime-salt 
is most readily removed by boiling ? 

What relation has the organic matter to the nitric acid? Why is it 
not easy to make a biological or bacteriological examination of water? 

Into what four classes may water be divided? Name some of the 
characteristics of these different classes. 



CHAPTER III. 

Food. 

In order to preserve health and vigor it is necessary for 
animal beings to consume at intervals a sufficient quantity of 
substances known as foods. Alimentary substances, or foods, 
may, therefore, be briefly defined as materials which, taken into 
the body and assimilated, sustain the processes of life, promote 
growth, or prevent destruction of the organized constituents of 
the body. 

QUANTITY AND CHARACTER OF FOOD NECESSARY. 

It has long been known, as the result of the empirical 
observation of feeding large bodies of people, that the various 
proximate principles composing the tissues must be combined in 
certain definite proportions in the food in order to preserve the 
normal degree of health and vigor of the body. Within a 
comparatively recent period physiologists have made experi- 
ments upon animals and human beings which have led to the 
same conclusions, and have enabled these proportions to be 
fixed with more or less exactness. 

Considering man as an omnivorous animal, it may be laid 
down as an invariable rule that the following four alimentary 
principles are necessary to his existence. 1 Neither of these 
principles can be dispensed with for a prolonged period without 
illness or death resulting. 

1. Water. — This must be supplied in sufficient quantity 
to permit the interchange of tissue to be carried on in the body. 

2. Salts. — Inorganic compounds of various kinds are 

1 Physiologie, Landois, 2te Aufl., p. 448. 

(87) 



88 TEXT-BOOK OF HYGIENE. 

necessary to the preservation and proper construction of the 
tissues. They are all found in sufficient quantities in the 
various alimentary substances consumed by man and the lower 
animals. A deficiency of inorganic constituents in the food is 
followed by disease. 

3. Proteids. — Organic nitrogenous material, either animal 
or vegetable, is a necessary constituent of the food of man. 
Continued existence is impossible without a sufficient supply of 
nitrogenous substances. 

4. Fats or Carbohydrates. — The organic non-nitrogenous 
or carbonaceous principles of food are also necessary to the 
continuance of health. They are supplied either by fats or by 
carbohydrates (sugar, starch, etc.), which may, within certain 
limits, be used as substitutes for each other. Voit has shown 
that 17 parts by weight, of starch, is equivalent as carbonaceous 
or oxidizable food to 10 parts of fat. 

The physiology of nutrition has been very carefully studied 
by a large number of experimental physiologists, who have 
arrived at conclusions differing widely from those generally 
accepted twenty-five years ago. The division of foods into 
plastic and respiratory foods, or, in a general way, into proteids 
or muscle-builders, and fats and carbohydrates, or oxidizing 
foods, is now no longer recognized in science. It has been 
established that proteid tissues are not alone the result of proteid 
food, and that the accumulation of fat in the body is not altogether 
due to the excessive consumption of fats and carbohydrates. It 
has been further shown, contrary to the general belief, that the 
nitrogenous or proteid tissues are not used up during hard labor 
any faster than when at perfect rest, but that, on the contrary, 
increased rrmscular exertion is attended by increased consump- 
tion of stored-up fat. 

These facts have led to a modification of the standard 
dietaries formerly employed. At present the standards of the 
quantity of food principles required to maintain equality between 
bodily income and expenditure are those calculated by Professor 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 



89 



Voit, after many experiments upon human beings and the lower 
animals. These standards are as follow : — 





Table VII. 

ADULT MALE OF AVERAGE WEIGHT. 






At Rest. 


Moderate Labor. 


Severe Labor. 


Proteids . . 
Fats .... 
Carbohydrates 




110 grammes 
50 " 
450 " 


118 grammes 
50 " 
500 " 


145 grammes 
100 " 
500 u 



As the average weight of women is less than that of men, 
a reduction of from 15 to 20 per cent, in the various food prin- 
ciples may be made for the female ration. 

The relative proportion of nitrogenous to non-nitrogenous 
principles in this ration is about 1 to 5. In the older diet 
standards, e.g., Moleschott's, the proportion of nitrogenous to 
non-nitrogenous principles is much larger, being, for a man at 
moderate labor, proteids, 130 grammes; fats, 84 grammes; and 
carbohydrates, 404 grammes, or about 1 to 3.T5. 

While from ignorance, or motives of economy, many men 
sustain life and preserve health at hard labor on rations varying 
considerably from the standard above given, it is probable that, 
all things being considered, the most perfect physiological ration 
would also be the most economical. Thus, Professor Vaughan 
proposes a daily ration consisting of bread, cod-fish, lard, potatoes, 
bacon, beans, milk, sugar, and tea in such proportions as to fur- 
nish 123 grammes proteids, 70 grammes fats, and 550 grammes 
carbo-hydrates. The total cost or money value of this ration at 
present prices is about thirteen cents. In actual food value it 
is not inferior to the daily fare of the habitue of Delmonico's. 

The above standard diet-tables give the relative proportions 
of food principles in terms of their proximate chemical composi- 
tion. In practice it is very necessary to choose such food ma- 
terials as will represent approximately the proximate principles 



90 



TEXT-BOOK OF HYGIENE. 



required. The following tables give the approximate value in 
proteids, fats, carbohydrates, and salts of a number of articles 
used as food: — 

Table VIII. 



ANIMAL FOODS. 



Articles. 








CO 


O 








C cc~ 








dSp 




•s a 


m a 


W)oj a 


H CI 




+? o> 


C +J CD 


"S « 


is 


C5 o 




<z 


^& 


<o 


Cg cp 


a> 


Pi 


A a 


Pj 






o w 

to 




21.39 


5.19 




1.17 


21.51 


7.47 


0.16 


0.78 


18.88 


7.41 


0.07 


1.33 


18.11 


5.77 




1.33 


19.91 


6.81 




1.10 


22.32 


8.68 




6.42 


23.34 


1.13 


0.19 


1.18 


19.77 


1.92 


1.42 


1.13 


21.71 


2.55 


0.46 


1.01 


15.93 


26.33 


6.38 


2.66 




60 79 




17.51 


19.72 


1.42 


1.27 


1.37 


22.14 


1.00 


0.76 


1.00 


22.65 


3.11 


2.33 


1.09 


17.09 


0.35 




1.64 


10.11 


7.11 




2.07 


22.23 


0.47 




1.71 


23.42 


6.76 




1.85 


13.57 


5.02 


0.39 


1.11 


13.10 


4.57 


4.67 


1.28 


20.61 


1.09 




1.33 


20.11 


0.69 


0.92 


0.83 


11.94 


0.25 


0.45 


1.22 


4.95 


0.37 


2.62 


2.37 


31.90 


14.14 




8.91 


19.59 


5.60 


1.10 


1.69 


(8 albumen) 


13.14 




1 


27.00 


0.35 


11.65 


1. 


9.72 


75.75 




5.38 


12.55 


12.11 


0.55 


1.12 


12.67 


0.25 




0.59 


16.24 


31.75 


0.13 


1.09 


3.31 


3.66 


4.92 


0.70 


2.48 


3 90 


6.04 


0.49 


3.70 


25.72 


3.54 


0.63 


27.16 


30.43 


2.53 


4.13 


32.65 


8.41 


6.80 


4.12 


0.86 


83.11 


0.70 


1.19 


0.82 


0.24 


4.98 


0.65 


2.83 


0.94 


7.08 


1.07 


16.07 


12.10 


38.882 


2.61 



o o 

r- 22 P • 
g 3 01 02 

•HIS 

IP* 



Moderately fat beef . . 
Ox-heart (fat animal) . 

Fat veal 

Moderately fat mutton 

Lean pork 

Salt ham 

Hare 

Venison 

Horse-flesh 

Liver-sausage 

Beef-extract 

Chicken (lean) 

Pigeon 

Wild duck 

Haddock 

Herring (fresh) . . . . 

Roach 

Mackerel 

Conger-eel 

Salmon 

Carp . 

Pike 

Sole 

Oyster 

Caviar 

Beef-liver 

Calf s brains . . . . . 

Sweet-bread 

Fat of pork (salt) . . . 



White of egg 

Yelk of egg 

Cow's milk 

Human milk 

Cream 

Rich cheese 

Lean cheese 

Butter 

Whey .... . . . 

Kumys 

Condensed milk. . . . 



0.4 
0.6 
0.7 
0.6 
0.6 
0.7 
0.1 
0.2 
0.2 
3.3 

0.2 
0.1 
0.3 
0.0 
0.0 
0.0 
0.5 
0.7 
10 
01 
0.1 
0.1 
0.7 
0.8 
0.5 



13.6 
1.7 
0.1 
3.4 
3.4 
5.2 
13.1 
2.1 
0.7 
169.9 
6.6 
3.1 
37 



1 Containing 16 per cent, nitrogen. 



Containing 22.26 per cent, cane-sugar. 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 



91 



Table IX. 

VEGETABLE FOODS. 



Articles. 



Wheat 

Spelt 

Rye 

Barley 

Oats 

Indian corn . . . 
Hulled rice. . . . 

Millet . 

Buckwheat. . . . 

Beans 

Peas 

Lentils 

Wheat-flour . . . 
Rye-flour/. . . . 
Barley -flour . . . 
Buckwheat-flour . 

Oatmeal 

Cornmeal ... 

Starch 

Macaroni 

Fine wheat-bread 
Fresh rye-bread . 
English biscuit. . 

Potatoes 

Beet (red) . . . . 
Sugar-beet . . . , 
Mangold root. . . 
Carrot (large) . . 
" (small) . , 

Turnip 

Radish , 

Horseradish . . , 
Kohlrabi . . . , 

Onion , 

Leek 

Garlic 

Cucumber . . . . 

Melon , 

Pumpkin. . . . , 
Tomato . . . . , 
Asparagus . . . . 
Green peas. . . , 
Snap beans. . . , 
Cauliflower. . . . 
"Winter cabbage. . 
Savoy cabbage . 
Red cabbage . . 
Spinach .... 
Lettuce .... 



5a 

- 



e3 o 



12.42 

11.02 

11.43 

11.16 

11.73 

10.05 

7.81 

11.29 

10.58 

23.66 

22.63 

24.81 

8.91 

10.97 

11.75 

9.28 

15.50 

11.10 

1.46 

9.02 

6.82 

6.02 

7.18 

1.79 

1.07 

2.08 

1.40 

1.04 

1.04 

0.96 

2.92 

2.73 

2.95 

2.68 

2.83 

6.76 

1.02 

1.06 

0.71 

1.25 

1.98 

5.75 

4.67 

2.53 

3.99 

3.31 

4.83 

3.15 

1.41 



1.70 
2.77 
1.71 
2.12 
6.04 
4.76 
0.69 
3.56 
2.79 
1.63 
1.72 
1.85 
1.11 
1.95 
1.71 
1.89 
6.11 
8.10 

0.28 
0.77 
0.48 
9.28 
0.16 
0.11 
0.11 

0^21 
0.21 
0.16 
0.11 
0.35 
0.22 
0.10 
0.29 
0.06 
0.09 
0.61 
0.05 
0.33 
0.28 
0.50 
0.30 
0.38 
0.90 
0.71 
0.46 
0.54 
0.31 



1.44 

0.96 

2^22 
4.59 

l!l8 



2.32 
3.88 
3.10 
1.06 
2.25 



2.37 
2.54 

17.02 

6.55 
9.31 
4.68 
6.74 
1.60 
4.08 
1.53 

0^40 

5.78 
0.44 

0^95 
0.27 
1.36 
2.53 
0.40 



1.27 
1.21 
1.29 

0.08 



It 



fit . 

fee 

^ ® 



£~ 



66.45 

66.44 

66.86 

65.51 

53.21 

62.19 

76.40 

66.15 

55.84 

49.25 

53.25 

54.78 

71.86 

65.86 

67.80 

71.40 

61.42 

65.10 

83.31 

76.79 

49.97 

45.33 

58.08 

20.56 

2.43 

2.41 

2.14 

2.66 

7.17 

1.90 

6.90 

15.89 

8.45 

19.91 

6.09 

26.31 

1.33 

1.15 

5.87 

1.55 

2.34 

10.86 

6.60 

3.74 

10.42 

4.73 

6.22 

3.26 

2.19 



2.66 
5.47 
2.01 
4.80 

10.83 
2.84 
0.78 
4.25 

16.52 
7.47 
5.45 
3.58 
0.33 
1.62 
0.11 
0.89 
2.24 



0.38 
0.30 
0.16 
0.75 
1.02 
1.14 

1.40 
0.95 
0.91 
1.55 
2.78 
1.76 
0.81 
1.49 
0.77 
0.62 
1.07 
1.36 
0.84 
1.14 
1.60 
1.69 
0.87 
1.88 
1.23 
1.57 
0.77 
0.73 



1.77 

2.21 



03 
.05 
.09 
.00 
.31 
.91 
3.15 
2.65 
2.47 
0.61 
1.48 
0.47 
1.21 
2.02 
1.70 
0.39 
0.84 
1.18 
1.31 
0.83 
0.57 
0.94 
1.04 
1.27 
0.90 
0.71 
0.75 
1.07 
1.53 
1.21 
0.54 
1.24 
1.44 
0.39 
0.63 
0.64 
0.63 
0.54 
0.80 
0.64 
0.82 
1.57 
1.64 
1.29 
1.94 
1.03 



agfi 

p£og 



5.7 
6.5 
6.2 
6.2 
5.6 
7.5 
9.9 
6.5 
5.7 
2.2 
2.5 
2.3 
8.5 
6.7 
6.3 
8.2 
4.8 
6.7 

57.1 
8.6 
7.9 
8.1 

1-2.7 

11.6 
8.6 
5.7 
5.8 
9.4 
8.8 
6.5 
4.5 
6.0 
3.1 
9.6 
2.5 
3.9 
2.4 
2.4 

10.2 
3.6 
1.6 
2.0 
1.5 
2.2 
3^3 
2.2 
1.5 
1.3 
1.9 



92 



TEXT-BOOK OF HYGIENE. 



Table IX (continued). 

VEGETABLE FOODS. 



Articles. 



Mushrooms (fresh) 
" (dried) 

Truffle 

Apples 1 

Pears 

Plums 

Peaches 

Apricots 

Cherries 

Grapes 

Strawberries . . . 
Raspberries . . . 
Blackberries . . . 
Mulberries .... 
"Whortleberries. , 
Gooseberries . . . 

Currants 

Dried apples . . . 

" pears . - . 

" prunes. . . 

" cherries . . 

" raisins. . . 

" figs ... . 
Sweet almonds . . 

Walnut 

Hazel -nut .... 
Chestnuts (fresh) 
Peanut 



91.11 
17.54 
72.80 
83.58 
83.03 
84.86 
80.03 
81.22 
80.26 
78.17 
87.66 
86.21 
86.41 
84.71 
78.36 
85.74 
84.77 
32.42 
2941 
29.83 
49.88 
32.02 
32.21 
5.39 
4.68 
3.77 
51.48 
6.50 



o , 

£1 



2.57 
23.84 
8.91 
0.39 
0.36 
0.40 
0.65 
49 
0.62 
0.59 
1.07 
0.53 
0.51 
0.36 
0.78 
0.47 
0.51 
1.06 
2.07 
2.55 
2.07 
2.42 
5.06 
24.18 
16.37 
15.62 
5.48 
28.20 



0.13 
1.21 
0.62 



0.45 



0.35 
0.53 
30 
0.59 

53.68 
62.86 
66.47 
1.37 
46.40 



1.05 
9.59 

'^73 

8 26 

3.56 

4 48 

4 69 

10.24 

14.36 

6.28 

3.95 

4.44 

9.19 

5.02 

7.03 

6.38 

41.61 

29.13 

42.65 

31.22 

54.56 

45.28 



Z%7 
saa 

O m 03 

& Pn ^ 

rt <C ® 

o 



3.71 

34.56 

7.54 

5.17 

3.54 

4.68 

7.17 

6.35 

1.17 

1.96 

0.48 

1.54 

1.76 

2 31 

0.87 

1.40 

0.90 

14.68 

29.67 

18.85 

14.29 

7.48 

7.23 

7.89 

9.03 

38.34 

15.70 



O 03 

I 5 



0.67 
6.21 

7 92 
1.98 
4 30 
4.34 
6.06 
5.27 
6.07 
3.60 
2.32 
5.90 
5.21 
0.91 
12 29 
3 52 
4.57 
5.59 
6 86 
1.43 
0.61 2 
1.72 

6.56 
6.17 
3.28 
1.61 



0.76 
7.05 
2.21 
0.31 
0.31 
0.66 
0.69 
0.82 
0.73 
0.53 
0.81 
49 
0.48 
0.66 
1.02 
0.42 
0.72 
1.96 
1.67 
1.39 
1.63 
1.21 
2.96 
2.96 
2.03 
1.83 
1.72 
3.20 



o3i . 

O Of fl « 

•■eg. a. 



1.9 

19 

1.0 

35.2 

33.3 

24 3 

19.3 

24.9 

19.9 

29.0 

78 

13.0 

14.5 

37.1 

9.7 

21.0 

18.5 

55.6 

29.1 

25.5 

22.2 

260 

8.9 

4.2 

7.2 

8.0 

7.5 

2.3 



In addition to maintaining a proper proportion between the 
various alimentary principles, it is necessary to vary the articles 
of food themselves, otherwise they are liable to prove nauseating. 
The necessity of variety in the food, in order to preserve the 
appetite, is familiar to every one. 

By keeping the proportions of the above table in view it 
will be seen at once that if a man wished to live on beef alone 
he would be obliged to eat about 2 kilogrammes per day in 
order to get a sufficient amount of non-nitrogenous food. Of 



' These groon fruits all contain in addition from .2 to 2.1 per cent, of free acid. 
3 Without stones. 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 93 

potatoes, in order to get enough nitrogenous food, he would have 
to eat daily 8 kilogrammes. No human stomach could prove 
equal to the task of digesting this excess of material. On the 
other hand, it is to be noted how perfect the combination of the 
various principles is in human milk. In cows' milk, which is 
nearest in composition to human milk, the non-nitrogenous 
principles are deficient. Hence, the important practical point 
that when ordering milk diet for a patient a small portion of 
carbonaceous food (bread, rice, or sugar) must be added if the 
standard of health shall be reached or maintained. 

Climate has probably very little influence upon the amount 
of food required by the individual. The actual quantity of food 
consumed varies little between various races or in different parts 
of the earth. It is true, however, that a larger proportion of fat 
is required in cold climates. That fatty articles of food readily 
undergo oxidation and furnish a large amount of animal heat is 
proven both by observation and experiment. 

The albuminoid proximate principles of the food, proteids, 
are represented by the nitrogenous constituents of organic 
tissues. These are the vitelhn and albumin of eggs, albumin, 
fibrin, globulin, myosin, syntonin, and other nitrogenized prin- 
ciples of flesh and blood ; the casein of milk, the gluten, fibrin, 
and legumin of cereal and leguminous seeds and plants, gelatin, 
and chondrin. 

Fat constitutes an integral component of animal tissue, and 
is found in abundance as a constituent of nerve-tissue, marrow, 
and subcutaneous connective tissue. In food it is represented 
especially in the fatty tissue of meat, the yelk of eggs, butter, 
etc. 

The carbohydrates are represented especially by various 
products of the vegetable world, as sugar, starch, dextrin, etc. 

Water and the various other inorganic proximate princi- 
ples, chief among which are compounds of calcium, sodium, and 
potassium, are usually found in sufficient proportion in the other 
alimentary substances. 



94 TEXT-BOOK OF HYGIENE. 

The food should be taken in appropriate quantities and 
properly prepared. A larger quantity than necessary may over- 
tax the digestive organs and thus yield less than the required 
amount of nutritive material to the body. 

Physical exertion increases the consumption of fatty prin- 
ciples. Hence, as in the cases of the athlete or prize-fighter in 
training, larger quantities of these principles are required to keep 
the nutrition of the body at the standard of health. During 
mental work, however, less carbohydrate material is consumed 
than during physical labor. 

The greater consumption of carbohydrates during muscular 

exercise is shown by the following table, which gives the amounts 

of carbon dioxide and nitrogen excreted by a man at rest and 

during labor : — 

Table X. 



At rest . 
At work 



CO, Excreted. 



912 grammes 
1284 " 



Nitrogen Excreted. 



36.3 grammes. 
36.3 " 



In youth the processes of combustion (production of carbon 
dioxide) go on with greater rapidity than after adult life is 
reached. For this reason young persons rarely get fat, the fat- 
producing food being burnt up in the body by the greater meta- 
bolic activity of the young cell. Hence, fats and carbohydrates 
should form a larger relative proportion in the diet of the young 
tkan in that of grown persons. 

Low external temperature causes a greater and more rapid 
consumption of fat than high external temperature. During 
febrile conditions, however, the destruction of stored-up fat in the 
body — the wasting away — is one of the most notable phenomena; 
hence the importance of supplying fat and fat-producing food 
in chronic febrile diseases. 

" Der Mensch ist was er isst" said Ludwig Feuerbach. 1 

1 Gottheit, Freiheit und Unsterblichkeit von Standpunkt der Anthropologic, p. 5. 



CLASSIFICATION OF FOODS. 95 

The pungency of the epigram is somewhat lost in the transla- 
tion, which is, literally, "Man is what he eats" The intimate 
relations of mental, moral, and physical conditions of health to 
the quality and quantity of food deserve the earnest attention 
of the educated physician and sanitarian. 

CLASSIFICATION OF FOODS. 

Foods and victuals are generally divided into foods proper 
and so-called accessory aliment. The classification is not exact, 
however, as the latter, which are commonly regarded as articles 
of luxury, may under certain circumstances become necessities, 
and hence should not be considered as forming a separate class. 

Foods are either of animal or vegetable origin. Those de- 
rived from animal sources are milk, the flesh of animals, birds, 
reptiles, and fish, and the eggs of the three last named. 

The foods derived from the vegetable kingdom comprise 
the seeds of various plants (cereals, legumes), roots, herbs, ripe 
fruits, the fleshy envelopes of various seeds (which may prop- 
erly be classed with the fruits), and various fungi. 

There are also in common use a number of beverages, e.g., 
water, alcoholic liquors, alkaloidal infusions (tea, coffee, cocoa), 
etc. 

In addition, a number of substances or compounds are in 
common use as condiments. Their function is either to render 
victuals more palatable, or to promote digestion and assimilation. 
Vinegar, mustard, and common salt are familiar examples. 

FOODS OF ANIMAL ORIGIN. 

Milk. — Human milk is, so far as known, the one perfect 
food for man found in nature. It contains, in proper proportion, 
representatives of all the different classes of proximate principles 
necessary to nutrition. One hundred parts contain about 2.5 
parts of proteids (casein and albumin) ; 3.9 parts of fat (butter) ; 
6.0 parts of sugar, and .5 of salts. The reaction of human 
milk is slightly alkaline ; that of fresh cows' milk is neutral. 



96 TEXT-BOOK OF HYGIENE. 

In human milk there are 12.9 parts of solid matter to 87.1 
of water, while in cows' milk the proportions are: Proteids, 4.0 
per cent,; fats, 3.4 per cent.; sugar, 3.8 per cent.; salts, 0.6 per 
cent., or 11.8 total solids and 88.2 water. 1 

Of the solids in milk, cows' milk contains more proteids, 
while human milk is richer in fats and sugar. Hence, in using 
cows' milk as a substitute for human milk the proteids are di- 
luted by the addition of water, and the non-nitrogenous com- 
ponents increased by adding sugar and, under some circum- 
stances, fat (cream). 

Goats' and asses' milk are sometimes used as substitutes 
for human milk, but they do not approach much nearer in com- 
position to the latter than does cows' milk. 

On standing, the fatty constituent of milk, the cream, sepa- 
rates, and on account of its less specific gravity rises to the 
surface, where it forms a layer of varying thickness. 

After standing a longer interval the milk undergoes certain 
physical and chemical changes. Lactic acid is formed at the 
expense of part of the sugar of milk (a sort of fermentation 
taking place), and, acting upon the casein, produces coagulation. 
This is the so-called " bonny-clabber." When the fermentation 
continues, especially under a slightly elevated temperature, the 
solid portion becomes condensed (curd), and a sweetish-acid, 
amber-colored liquid, the whey, separates. The curd, after 
further fermentation, under appropriate treatment, becomes 
converted into cheese. 

Whey is sometimes used alone or mixed with wine as an 
article of diet for the sick. 

Butter is made from the cream by prolonged agitation in a 
churn. The fat-globules adhere to each other and form a soft, 
unctuous mass, of a yellowish color, solid at ordinary tem- 
peratures. After the butter is all removed in this way the 
balance of the cream remains in the churn as buttermilk. This 
is an article of considerable nutritive value, although its excess 

1 Average of a number of analyses. 



FOODS OF ANIMAL ORIGIN. 97 

of acid renders it unsuitable as an article of diet in many 
cases. 

The specific gravity of fresh milk should not be below 
1030. It should, however, be borne in mind that the richest 
milk is not always that which has the highest specific gravity. 
In fact, a sample of rich milk, containing a large proportion of 
cream, may show, when tested with the lactometer, a lower 
specific gravity than a specimen of much poorer milk. Hence, 
the lactometer, although a useful instrument in guarding against 
excessive dilution of the milk with water, is not a very trust- 
worthy guide in determining the quality of the milk. 

Objections are often urged against the use of so-called 
" skim-milk," i.e., milk from which the cream has been removed. 
In some cities in this country the police, or representatives of 
the sanitary authorities, seize and confiscate all skim-milk found 
in possession of dealers. There appears to be no rational basis 
for the opinion held by many that skim-milk is not a proper 
and useful article of food. Before the lactic-acid fermentation 
has taken place it differs from fresh milk merely in the fatty 
and other matters removed in the cream. It contains nearly all 
of the proteids, sugar, and salts of whole milk, and may be used 
as an article of food with great advantage and entire safety. In 
certain diseased states it is of exceptional value as an article of 
diet. The sole objection of any weight to skim-milk is that it 
may be at times sold fraudulently as fresh milk. This is, how- 
ever, a question of little sanitary interest, but one principally of 
commercial ethics. 

Milk is frequently adulterated by the addition of water. 
More deleterious substances are rarely found. An excess of 
water gives the milk a bluish tinge and reduces its specific 
gravity. The addition of water may become especially dangerous 
by introducing the virus of some of the acute infectious diseases. 
Thus, the localized epidemics of typhoid and scarlet fevers have, 
in quite a number of instances, been traced to mixing the milk 
with water containing the poison of these diseases. It should, 



98 TEXT-BOOK OF HYGIENE. 

however, be stated that milk which contains the virus of typhoid 
fever has not necessarily been adulterated by the addition of 
water. The poison may have been introduced with the water 
used in washing the can, and adhered to the sides of the latter. 
In filling the can with milk a good culture medium is supplied 
in which the typhoid bacillus flourishes. 

It has long been a mooted question whether acute or chronic 
infectious diseases of the milk-giving animal may be communi- 
cated to persons using the milk of such animals. While there 
is little positive knowledge upon the subject, it would seem 
prudent to avoid the use of milk from diseased animals, if pos- 
sible, or to destroy any organic virus the milk may contain by 
previously boiling the milk. After thorough boiling little fear 
need be entertained of communicating either acute or chronic 
infectious diseases through this medium. Demme and Uffel- 
mann have reported cases which seem to demonstrate the pos- 
sibility of tuberculous infection through the medium of the milk. 
Professor Bang, of Copenhagen, has recently made a series of 
experiments and observations which has led him to the con- 
clusion that the milk of tuberculous cows and tuberculous 
women, in which there are no lesions in the mammary gland, 
only exceptionally contains the contagium. Professor Bang at 
the same time, however, points out that the milk from tubercu- 
lous udders is extremely dangerous, and that the tubercle bacilli 
are to be found not only in the milk itself, but in the cream, 
buttermilk, and butter made from it; and that such milk is 
sometimes infective by ingestion, even after exposure to 65° C. 
of heat, and by injection into the peritoneal cavity after exposure 
to 80° C. 

The infectiousness of the milk of cows suffering from 
splenic fever (milzbrand, anthrax) has been proven by Bollinger 
and Feser. Anthrax bacilli have been found in such milk by 
Chambrelent and Moussons. 

The agency of milk in the spread of scarlet fever is well 
recognized, but the manner in which the contagium gained 



FOODS OF ANIMAL ORIGIN. 99 

access to the milk was not well understood. Recently, however, 
an incident happened in England which seems to prove a close 
connection between this widespread and fatal disease and a dis- 
order in the milk cattle. The evidence in support of this view is 
as follows : Mr. W. H. Power, of the English Local Government 
Board, was detailed to investigate certain outbreaks of scarlet 
fever which seemed to have especial relation to the milk-supply 
from a particular dairy-farm. Upon inspection this dairy was 
found to be in excellent sanitary condition as regards cleanliness, 
water-supply, sewerage, etc., and for a time considerable difficulty 
was experienced in locating the cause of the outbreaks. Im- 
probable as it may at first sight appear, it seems to have been 
incontestably established that the epidemics of scarlatina were 
due to the use of milk obtained from cows attacked by a peculiar 
disease manifested by a vesicular eruption followed by ulceration 
of the udder. The chain of circumstances connecting the dis- 
ease in the cows with the outbreaks of scarlet fever in certain 
districts in London, supplied with milk from the diseased cows, 
was so strongly forged by the able investigator, into whose hands 
the work had been committed by the authorities, that hardly a 
doubt can exist that the one disease owed its origin to the other. 

The pathological evidence furnished by Dr. Klein lends 
strong support to the view that the Hendon cow disease and 
scarlet fever are intimately related to each other. A bacterial 
organism was found in the material from the ulcerated udders 
of the sick cows, which presents similar characters to a micro- 
coccus found by the same observer in the blood of scarlet-fever 
patients. These results require more extended investigations 
before they can be unreservedly accepted. 

The milk of cows fed upon the refuse of breweries and dis- 
tilleries — "swill-milk" — is believed by many physicians to be 
unwholesome. If so, it is, probably, only by reason of the un- 
favorable hygienic conditions under which the animals are kept. 
If the stables are clean, dry, and well ventilated, and the ani- 
mals receive plenty of fresh air and exercise, swill-fed cows 



100 TEXT-BOOK OF HYGIENE. 

should produce as nutritious milk as when they are fed upon 
different food. Much of the present agitation against "swill- 
milk" is more prompted by political demagogism than by 
scientific knowledge. 

The milk of animals suffering from certain diseases is often 
dangerous to health. In some of the Western and Southern 
United States, cows are not infrequently attacked by an acute 
febrile disease called " the trembles," from one of the prominent 
symptoms. The milk of cows suffering from this disease pro- 
duces severe gastro-intestinal disorder, collapse, fever, etc., in 
the consumer. This disease, called " milk-sickness," is fatal in 
a pretty large proportion of cases. It is said that the flesh of 
animals with u the trembles" will, if eaten, produce similar dan- 
gerous effects. A late writer (Dr. Beach, of Ohio) estimates 
that 25 per cent, of the Western pioneers and their families 
died of this disease. 

For the ready determination of the quality of milk, instru- 
ments known as lactoscopes, lactometers, and creamometers are 
used. The lactoscope indicates the opacity of the milk, upon 
which the proportion of cream depends. One convenient mod- 
ification of the lactoscope is the little instrument termed the 
pioscope. This consists of a disk about 6 J centimetres in diam- 
eter, with a slight depression in the centre. A little milk is 
placed in the depression and covered with a glass disk, clear 
in the centre and opaque around the border, which is divided 
into six divisions of different shades, varying from white to 
dark gray. The quality of the milk is marked upon the 
division whose color corresponds with that of the milk in 
the centre. 

A better, but still not very accurate, indicator of the quality 
of the milk is the cream ometer. This consists of a cylindrical 
glass vessel with the upper half divided up into hundredths. 
The glass is filled up to the zero mark with milk, and allowed 
to stand until all the cream has separated. The thickness of 
this layer is then read off on the scale. In Chevallier's instru- 



FOODS OF ANIMAL ORIGIN. 



101 



ment, 10 per cent, of cream is the minimum proportion that 
should be furnished by the milk. 

The specific gravity, which is a fair guide to the quality of 
the milk, with the reservations above mentioned, is measured by 
means of the lactometer or lactodensimeter. The specific 
gravity of good cows' milk should not be less than 1029. 

In order to prevent the rapid fermentation of milk various 
methods of preservation have been adopted. The addition of 
alkalies, or antiseptics, retards the lactic-acid fermentation, while 
the abstraction of a portion of 
the water and addition of sugar 
(condensed milk) preserves it 
for an indefinite time. The 
mere addition of water restores 
it to nearly its original condition. 

Tyrotoxicon in Milk. — This 
substance, first found in poison- 
ous cheese, and later in milk, ice- 
cream, custards, etc., is believed 
by Professor Vaughan to be the 
cause of true cholera infantum, 
and many of the clinical phe- 
nomena of this disease lend 
strong support to such a view. 
The conditions under which the 
poison is developed have not yet 
been sufficiently studied to enable correct conclusions to be drawn. 

Butter. — Butter is of especial value as food on account of 
the large amount of easily digestible fat which it contains. It is 
almost always used as accessory to other articles of food, to ren- 
der them more palatable. When pure and fresh, it is one of the 
most delicious of creature comforts. It soon undergoes the 
butyric-acid fermentation, however, becoming "rancid," as it is 
termed, when it is unfit for food. 

The great demand for butter and its consequent high price 




Fig. 3. — Chevallier's Creamometek. 



102 TEXT-BOOK OF HYGIENE. 

have led to its extensive sophistication. Butter is now very 
largely substituted by an artificial product termed oleo-margarine, 
or butterine. This artificial butter is made from beef-suet by the 
following process : Fresh beef- fat is melted at as low a temperature 
as possible, never higher than 52° to 53° C. [126° to 128° F.J 
All membrane and tissue are then removed, and the resulting 
clear fat is put into presses, where the stearine is extracted. 
The liquid fat, free from tissue, and with nearly all its stearine 
removed, is known as " oleo-margarine oil." The next step 
in the process is " churning." The oil is allowed to run into 
churns containing milk and a small quantity of coloring 
material (annatto), where, by means of rapidly-revolving pad- 
dles, it is churned for about an hour. When this part of the 
process is complete, the substance is drawn off from the 
bottom of the churn into cracked ice. When cool it is taken 
from the ice, mixed with a proper quantity of salt, and is then 
worked like butter and put into firkins for the market. It is 
also molded into attractive prints in imitation of dairy-butter. 1 
When the materials from which oleo-margarine is made are 
sweet and clean, and when the process of manufacture is prop- 
erly conducted, the resulting product is an entirely harmless 
article, and probably differs very little in nutritive value from 
butter itself. 

Cheese. — The value of cheese as a food depends upon the 
large amount of proteids and fat which it contains. The rich 
varieties of cheese, such as Fromage de Brie and Roquefort, con- 
tain on an average 35 per cent, of fat and 27 per cent, of proteid 
compounds. Parmesan contains only about 18 per cent, of fat 
and nearly 40 per cent, of proteids, while Edam and Cheshire 
cheese, which may be considered as standing about midway 
between the above, contain 30 per cent, of fat and nearly 28 
per cent, of proteids. From these figures it appears that cheese 
is one of the most nutritious aliments obtainable, but it cannot 

1 Dr. W. K. Newton, P'ifth Annual Report of the State Board of Health of New Jersey, 
1881, p. 107. 



FOODS OF ANIMAL ORIGIN. 



103 



be eaten in large quantities at a time, as it is exceedingly liable 
to cause disturbances of the digestive organs. The constipating 
property of cheese is well known to the public. 

The relative value of different kinds of cheese in alimentary 
principles is given in the following table: — 





Table XI. 






Kind of Cheese. 


Proteids 
(per cent.). 


Fats 
(percent.). 


Sugar 
(per cent.). 


Salts 
(percent.). 


Cheshire 


27.68 


27.46 


5.89 


5.01 


Edam 


24.07 


30.26 


4.48 


4.91 


Holland 


29.48 


26.71 


2.27 


4.62 


Roquefort 


27.69 


33.44 


3.15 


5.35 


Neufchatel 


17.44 


40.80 


5.21 


2.05 


Parmesan 


41.19 


19.52 


1.18 


6.31 



Cheese is not often adulterated. The only articles used 
with success in its sophistication are lard and oleo-margarine, 
which are incorporated with the casein during the process of 
manufacture. • It sometimes undergoes chemical changes which 
render it intensely poisonous when eaten. 

Prof. V. C. Vaughan, of the University of Michigan, has 
ascertained that the substance causing the poisonous symptoms 
is a chemical compound termed by him tyrotoxicon. This 
same poison has also been found by Professor Vaughan and 
other chemists in ice-cream and fresh milk, which produced 
poisonous symptoms when consumed. The poison is supposed 
to be a ptomaine produced by the agency of a micro-organism, 
which has, however, not yet been isolated. 

Meat — The flesh of mammals, reptiles, birds, fish, and 
invertebrate animals is used as food by man. Falck 1 has classi- 
fied the varieties of animals which furnish food to the inhabitants 
of Europe. There are 47 varieties of the mammalian class, 
105 of birds, 7 of amphibia, 110 of fish, and 58 of invertebrates. 

1 Das Fleisch, Gerneinverstaendliches Handbuch der Wissenschaftlichen und Praktischen 
Fleischkunde. 



104 



TEXT-BOOK OF HYGIENE. 



Meat is the most important source of proteids in the food. 
In the more commonly used varieties of meat the proteids and 
fats constitute from 25 to 50 per cent, of the entire bulk, the 
proportion depending largely upon the age of the animal and its 
bodily condition. The following table shows the influence of 
these two factors upon the relative proportions of the fats and 
proteids contained in the meat: — 

Table XII. 1 



Proteids (per cent. 



Fats (per cent.). 



Moderately fat beef 
Lean beef . . . . 

Veal 

Very fat mutton 
Fat pork . . . . 
Lean pork . . . . 

Hare 

Lean chicken . . , 



21.39 
20.54 
10.88 
14.80 
14.54 
19.91 
23.34 
19.12 



5.19 
1.78 
7.41 
36.39 
37.34 
6.81 
1.13 
1.42 



The flesh of animals, which is neutral in reaction immedi- 
ately after death, soon becomes acid in consequence of the 
formation of lactic acid. The acid, acting upon the sarcolemma 
and the muscular fibre, renders it softer and more easily per- 
meable by fluids when cooking, and more susceptible to the 
action of the gastric juice when the meat is taken into the 
stomach. 

Certain kinds of meat — mutton and venison, for example — 
are often kept so long before being eaten that a considerable 
degree of putrefaction has taken place when they are brought 
upon the table. The wisdom of this practice is questionable 
from a hygienic point of view. 

Meat is sometimes eaten raw, but it is usually first cooked. 
The methods of cooking in general use are boiling, frying, 
roasting, broiling, and baking. By either of these methods of 



1 Abridged from Loebisch; article "Fleiscb" in Realencyclopaedie d. ges. Heilkunde, 
vol. v, p. 340. Fuller details will be found in Table VIH. 



FOODS OF ANIMAL ORIGIN. 105 

cooking, when properly carried out, the nutritious properties of 
the meat are preserved, and it is rendered digestible. The 
culinary art deserves the closest attention of students of hygiene. 

A number of soluble preparations of meat (beef-extract, 
beef-essence, beef-juice) are found in the market, and highly 
recommended as containing all the nutritious qualities of the 
meat from which they are prepared. These, and similar products 
of domestic preparation (broths and teas), contain in reality 
very little nutritive material, but are of use almost solely as 
stimulants to the appetite and digestion. They have a place in 
the dietary of the sick, but their nutritive value is small. 

On the other hand, a number of partly or wholly predi- 
gested (peptonized or pancreatized) preparations of meat are 
offered for sale, many of which have a high nutritive value. 
They cannot, however, be used as articles of diet except for a 
short time, or as a temporary succedaneum for meat in diseases 
attended with weakness or derangement of the digestive organs. 

Meat may be unfit for food from various causes. Thus 
the flesh of animals dying from certain diseases — splenic fever, 
pleuro-pneumonia, tuberculosis in its advanced stages, cow- or 
sheep- pox — should not be used as food when it can be avoided. 
Cases are on record proving the poisonous character of meat 
from animals which suffered, at the time of death, from some of 
the above-mentioned diseases. The most important condition 
to be borne in mind is that certain parasites (trichina spiralis, 
echinococcus, cysticercus), which frequently infest the flesh of 
animals, especially hogs, not infrequently give rise to serious or 
even fatal diseases in persons consuming such meat. Any meat 
containing these parasites, or suspected of containing them, 
should therefore not be used as food unless precautions be first 
taken to destroy the life of the parasite. 

Of the parasites mentioned the trichina spiralis is the most 
important in this connection, as it frequently occurs in the flesh 
of hogs, rats, dogs, cats, and other carnivorous animals. Eats 
are said to be infested with the parasite more frequently than 



!()() TEXT-BOOK OF HYGIENE. 

any other animals. The trichinae are found in two forms, one, 
the mature form, inhabiting the intestinal canal. The immature 
form, or muscle trichinae, are found in striped muscle, coiled into 
spirals and encysted in a fibrous capsule. They gain access to 
their host in the following manner: Flesh containing living 
trichinae is taken into the stomach, where the muscular tissue 
and the fibrous envelope are dissolved, and the inclosed worms 
set free. These mature in the intestinal canal, where sexual 
reproduction takes place, and the young embryos pass through 
the intestinal walls and other tissues until they become imbedded 
in striated muscle. Localized epidemics of trichinosis have 
been reported in this country and Europe, and in nearly every 
instance the source of the disease has been traced to the inges- 
tion of uncooked pork. Meat known to be trichinous should 
not be used unless in times of great scarcity. It may, however, 
be rendered innocuous by thorough cooking. A temperature 
of 60° to 70° (140° to 160° F.) destroys the life of the parasite 
and renders the meat safe. On account of the frequent occur- 
rence of trichinae in pork, this meat should never be eaten unless 
thoroughly cooked. It has been ascertained that salted and 
smoked pork is not free from danger, as the parasites are not 
killed in the process of curing the meat. Hence, ham and 
sausage should not be eaten raw, as the danger from these 
articles is almost equally as great as from fresh pork. 

Cystlcercus celhdosa, the transition form of one variety of 
tape- worm, and which is the parasite in measly pork, may also 
gain entrance to the human body, and, failing to undergo devel- 
opment, cause very serious lesions of various organs and tissues. 
The frequency of tape-worm is evidence that pork is often thus 
diseased. 

The use of partially decayed meat or fish has often been 
the cause of serious or fatal illness. Sometimes the illness par- 
takes of the character of septic infection. In these cases it is 
probable that the morbid process is due to the action of the 
organisms of putrefaction. In other cases the symptoms are 



FOODS OF ANIMAL ORIGIN. 107 

widely different. These cases have been the source of much 
perplexity to physicians and toxicologists until very recently. 
Within the past six years, however, Selmi, Husemann, Brouardel, 
Casali, and others have drawn attention to certain intensely 
poisonous chemical compounds found in decomposing flesh, and 
which have been named by Selmi ptomaines. While there is 
still much uncertainty concerning the nature of these compounds, 
it seems pretty well established that when flesh undergoes de- 
composition, in the absence of oxygen, certain unstable chemical 
combinations are formed which act as violent poisons. Selmi, 
followed by most toxicologists, believes these compounds to be 
alkaloids, analogous to the vegetable alkaloids, such as morphine, 
atropine, etc. Casali, on the other, hand, disagrees with this 
opinion, and believes the ptomaines to be amido compounds. 
Husemann regards Casali's hypothesis as plausible, inasmuch as 
the formation of amido compounds in animal and vegetable 
bodies during decomposition is well established. 

The form of poisoning due to the organisms of putrefaction 
is not infrequent. An extensive outbreak of this nature occurred 
at Andelnngen, in Switzerland, in 1839. A musical festival 
was held, at which there were over 700 present. Out of these 
444 were suddenly attacked by violent gastro-enteric and nervous 
symptoms. Ten of the patients died. The illness was traced to 
roast veal, which had been kept in a warm place for two days 
after roasting, and which was probably in a state of partial 
decomposition. 

The class of cases which seem more probably due to the 
action of ptomaines or related poisons, have been frequently 
observed after eating sausages or canned meats. Sausage poi- 
soning is not rarely observed in Germany. It has been ascer- 
tained that the internal portions of the sausage are the most 
poisonous. It is supposed that the ptomaines, \yhich are formed 
in the absence of oxygen, are the active agents in the pro- 
duction of the train of symptoms. Poisoning by canned meat 
seems to be due to a similar poison. 



108 TEXT-BOOK OF HYGIENE. 

In July, 1885, an outbreak of disease, due to eating un- 
wholesome beef, was caused at Momence, Illinois. Chemical 
examination of specimens of the meat showed the presence of 
an alkaloidal body, which was believed to be a ptomaine, but its 
nature was not definitely determined. 

Fish, oysters, crabs, and lobsters frequently give rise to 
symptoms of poisoning. In most of these cases the poisoning 
is probably due to partial decomposition, but it is a well-known 
fact that oysters and crabs are unfit for food at certain seasons. 
Some persons, however, are subjects of a peculiar idiosyncrasy, 
in consequence of which shell-fish always produce certain un- 
pleasant symptoms, among which nettle-rash and a choleraic 
attack are most prominent. 

That form of fish-poisoning known among the Spaniards 
in the West Indies as siguatera is, however, very grave. The 
mortality is large, and in many cases death succeeds rapidly 
upon the attack. The symptoms are as follow: Sometimes 
suddenly, sometimes preceded by dizziness and indistinct vision, 
great prostration and paralysis occur. Often death follows the 
onset of the symptoms in two and three hours ; exceptionally in 
less than twenty minutes. In most cases consciousness is totally 
lost; in others it persists, with interruptions, until death. Sensa- 
tion and the powers of speech and deglutition fail. The jaw- 
muscles become paralyzed, the pulse is slowed, and the tem- 
perature diminished. There is sometimes vomiting, but no 
purging. The secretion of the kidneys is also checked. Dr. 
McSherry states 1 that he has seen all these symptoms produced 
by eating oysters, lobsters, and crabs unseasonably. 

In Russia a form of poisoning has often been observed 
which results from eating salted sturgeon. In the fresh state 
these fish are perfectly wholesome, but when salted and eaten 
raw they produce a very fatal illness. The mortality is said to 
reach 50 per cent, of those attacked. No cases traceable to 
this cause have been observed in this country. 

1 Health and How to Promote it, p. 143. 



FOODS OF ANIMAL ORIGIN. 109 

It has been shown, beyond question, that the flesh of beeves 
suffering, when killed, from splenic fever, will produce this 
disease in the human subject. 

In 1874 an extensive and violent outbreak of an acute 
disease, characterized by vomiting and purging, fever and dizzi- 
ness, occurred at Middelburg, hi Holland. Three hundred and 
forty-nine persons were attacked, of whom 6 died. The out- 
break was traced to eating liver-sausage (Leber wurst), in which 
the characteristic bacillus of splenic fever was found on micro- 
scopic examination. In July, 1877, an outbreak of choleraic 
disease, from eating carbuncular meat, occurred in the town of 
Wurzen. In the latter epidemic the bacillus of splenic fever 
{Bacillus anthracis) was found in the intestinal canal and in the 
blood of those attacked. 

In Detmold, in Germany, an outbreak of violent gastro- 
intestinal inflammation, accompanied by high fever, occurred. 
Among the 150 persons attacked 3 died. The disease was 
traced to eating the meat of a cow suffering, before death, 
from pleurisy (probably pleuro-pneumonia). In view of the 
somewhat extensive prevalence of this disease among cattle in 
this country at the present time, the record of this outbreak may 
suggest to sanitary authorities some measures for the prevention 
of similar epidemics on this side of the Atlantic. 

In July, 1880, 72 persons who had eaten of certain beef 
and ham-sandwiches in AYelbeck, England, were attacked by 
choleraic diarrhoea; 4 of the cases died. Inflammation of the 
lungs and small intestines were the most prominent pathological 
conditions found post-mortem. The smaller blood-vessels of the 
kidneys were filled with finger-shaped bacilli, which, when cul- 
tivated and inoculated into guinea-pigs, rats, and white mice, 
produced similar pathological conditions. At Nottingham, 
England, in 1881, a number of persons were attacked by a 
similar train of symptoms after eating baked pork. One case 
terminated fatally out of the 15 attacked. It is uncertain 
whether the meat in these two instances was from diseased 



110 TEXT-BOOK OF HYGIENE. 

animals or whether it had undergone partial decomposition. 
The former is the more probable supposition, although the 
organisms found were neither those of splenic fever nor swine 
plague, but resembled those of symptomatic anthrax (black leg 
or black quarter). 

Whether the flesh of tuberculous animals can communicate 
tuberculosis to the consumer is still an unsettled question. 
Foreign veterinarians and hygienists who have studied the 
question incline to the view that there is danger of such trans- 
mission. At the International Sanitary Congress of 1883, at 
Brussels, the subject was discussed, and M. Lydtin, the chief 
-veterinary surgeon of the Grand Duchy of Baden, submitted 
the following propositions, which were adopted by the Congress : 

1. That the flesh and viscera of tuberculous animals may 
be used as food, provided the disease is only commencing, the 
lesions extending but to a small part of the body, the lymphatic 
glands being still healthy; provided the tubercle centres have 
not undergone softening, and provided the carcass is well nour- 
ished and the flesh presents the characters of meat of the first 
quality. 2. That the flesh of animals showing very pronounced 
tuberculous infection should be saturated with petroleum, and 
afterward burned under the direction of the police. 3. That the 
milk from cows affected with pulmonary phthisis, or suspected of 
having it, should not be consumed by man or other animals, 
and the sale of it should be strictly prohibited. 

The congress for the study of tuberculosis, which met in 
Paris in 1888, adopted resolutions of a more decided character 
against the use of meat and milk from tuberculous animals. 

Certain animals can devour with impunity substances 
which are intensely poisonous to human beings. The flesh of 
the animals may be impregnated with these poisons, and cause 
serious and fatal illness in persons partaking of it. In this way 
may, perhaps, be explained the cases of poisoning sometimes 
following the eating of partridges and other birds. 

The prevention of disease from tainted meat is one of the 



FOODS OF ANIMAL ORIGIN. Ill 

most important problems of public hygiene. Food animals 
should be inspected by qualified inspectors before slaughtering, 
to exclude animals suffering from diseases that would vitiate the 
meat. When the meat is exposed for sale upon the dealer's 
stall it should be again inspected, and all found unfit for use as 
food confiscated and destroyed. Meat, in which the presence 
of trichinae or other parasites is suspected, should be examined 
microscopically. 1 

Eggs. — Although eggs contain a large amount of the pro- 
teid and fatty alimentary principles, 2 their value as food has 
probably been greatly overrated. The savory taste and ready 
digestibility of eggs has. however, rendered them a popular 
article of food. For obvious reasons, the eggs of the common 
barn-yard fowl are most frequently used, those of ducks and 
geese being far inferior in flavor to the first named, and being 
likewise less easily obtained. 

The method of cooking eggs is generally supposed to have 
considerable influence upon their digestibility. According to 
Dr. Beaumont's experiments made on Alexis St. Martin, raw 
eggs are digested hi one and a half to two hours, fresh-roasted 
in two hours and fifteen minutes, soft-boiled or poached in three 
hours, and hard-boiled or fried in three and a half hours. These 
experiments are, however, of very little value as a basis for 
general conclusions. It is probable that a hard-boiled egg is 
quite as easily digested in the healthy stomach as a raw one. if 
care be taken to masticate it well and eat bread with it, so that 
it is introduced into the stomach in a finely-divided state. 

Eggs readily undergo putrefaction, when sulphuretted 
hydrogen is formed in them hi large quantities. When this 
has taken place they are manifestly unfit to be used as food. 

1 The prevention of the diseases of animals hy National and State authorities is one of 
the most logical and thorough-going means of preventing disease from unwholesome meat. The 
American Public Health Association has for some years devoted considerable attention to the 
investigation of the diseases of animals and means for their prevention. The Department of 
the Interior of the National Government has likewise made the diseases of cattle and hogs a 
subject of study and published some valuable reports thereon. 

* See analysis in Table \TH. 



112 TEXT-BOOK OF HYGIENE. 

FOODS OF VEGETABLE ORIGIN. 

Bread. — The various cereal grains, when ground into flour, 
are used in making bread. The flours of wheat, rye, barley, 
buckwheat, and Indian corn are almost exclusively used in bread- 
making. The bran or cortical portion of grain contains a larger 
percentage of proteid principles than the white internal portion; 
hence, flours made from the whole grain (bran-flour, Graham 
flour) if finely ground are more nutritious than the white flours. 
The latter are, however, more digestible, and hence furnish a 
larger proportion of nutriment, because the principles contained 
in white flours are absorbed and assimilated to a greater degree. 

Good bread should be light, porous, and well baked. The 
lightness and porosity are due to carbon-dioxide gas imprisoned 
in cavities of the dough during the process of bread-making. 
By adding yeast to the dough a fermentation is caused in the 
latter, in consequence of which a portion of the starch is con- 
verted into sugar, and then into alcohol and carbon dioxide. 
During the process of mixing the dough the entire mass becomes 
permeated by the gas, which, on heating, expands and leaves 
the numerous large and small cavities throughout the loaf which 
indicate properly-made bread. 

Instead of yeast some persons use leaven, which is simply 
a portion of fermenting dough, saved from previous baking. A 
small quantity of this added to a mass of dough starts up the 
fermentation in a similar manner to that of yeast. 

The production of carbon dioxide by fermentation in the 
dough goes on at the expense of part of the starch. It has 
been proposed, therefore, to supply the carbon dioxide from 
without, thus saving the entire amount of the carbohydrates 
present in the flour. This is accomplished in two ways — 
first, by the use of some alkaline carbonate or bicarbonate 
(bicarbonate of sodium, carbonate of ammonium), the carbon 
dioxide being set free on the application of heat ; or, secondly, 
by forcing the gas, previously prepared, into the dough by means 
of machinery. 



FOODS OF VEGETABLE ORIGIN. 



113 



Flour is not infrequently adulterated with chalk, gypsum, 
pipe-clay, and similar articles. These are easily detected by 
adding a mineral acid, which produces effervescence when it 
comes in contact with the alkaline carbonate used as adulterant. 
Potato- and bean- meals are also used as adulterants of the higher 
grades of flour. Bakers often mix alum with inferior grades of 
flour. This imparts a greater degree of whiteness to the bread, 
and, in addition, enables it to retain a large proportion of water, 
thereby increasing the weight of the loaf. 

Formerly diseased grain (ergotized rye) often caused out- 
breaks of disease when the flour made from the diseased grain 
was used in bread-making. At the present time such accidents 
rarely occur. In some parts of Italy it is said that an endemic 
disease — pellagra — is caused by the consumption of diseased 
Indian corn. The evidence in favor of this view is, however, 
not unquestioned. 

Potatoes and rice are often used with satisfaction as substi- 
tutes for bread. They both contain a large proportion of carbo- 
hydrates. Indian corn (hominy) and oatmeal are likewise 
wholesome and nutritious foods of this class. 

The leguminous seeds (beans, peas, lentils) furnish a food 
containing a large percentage of proteids. According to the 
analyses of Kcenig l the average composition of the most fre- 
quently used legumes in the dried condition is as follows : — 

Table XIII. 



v 


Beans. 


Peas. 


Lentils. 


,'Ground-nnts. 3 


Water, per cent. . . . 
Solids, per cent. . . . 


13.6 

86.4 


14.3 

85.7 


12.5 

87.5 


6.5 
93.5 


Proteids, per cent. . . 

Fats 

Carbohydrates, per cent. 
Cellulose, per cent. . . 
Ash 


23.1 
2.3 

53.6 
3.9 
3.5 


22.6 
1.7 

53.2 
5.5 

2.7 


24.8 
1.9 

54.7) 
3.6 j 
2.5 


28.2 
46.4 

15.7 

3.2 



1 Die Menschlichen Nahrungs und Genussmittel, ii, p. 288. 

* The American pea-nut, the fruit or nut of Arachis hypogoea. 



114 TEXT-BOOK OF HYGIENE. 

Beans, peas, and lentils are often added to other articles of 
food with advantage. In recent years an important article of 
food for armies has been made of various legumes ground into 
flour and mixed with fat, dried and powdered meat, salt, and 
spice. This constitutes the so-called " Erbswurst," or pea-sausage, 
which formed such an important part of the dietary of the German 
army in the Franco-German war of 1871. Bean- and pea- meals, 
are also used sometimes as additions to other flours in bread- 
making. The dried leguminous fruits cannot be used as regular 
articles of diet, however, as they soon pall upon the taste, and 
produce indigestion, nausea, and other intestinal derangements. 

Green Vegetables. — The plants usually classed together as 
" vegetables," the products of the market-garden or truck-farm, 
comprise cabbages, turnips, parsnips, onions, beets, carrots, 
tomatoes, lettuce, green peas and beans, and similar articles. 
They all contain a large proportion of water, a variable propor- 
tion of sugar, and a small percentage of proteid principles. 
Much of their palatability and digestibility depend upon the 
methods by which they are prepared for the table. All garden 
vegetables should be used soon after being gathered, as they 
rapidly undergo decomposition, and are liable to produce 
derangements of the digestive organs if used under these 
conditions. 

Fruits and nuts generally contain large quantities of sugar 
and fats. They form agreeable additions to other articles of 
diet, but are insufficient to sustain life. The use of fruits usually 
produces copious intestinal evacuations, and they are, therefore, 
especially to be recommended to persons of sedentary occupations, 
in whom torpidity of the bowels is so frequently present. 

Condiments. — Various aromatic herbs and seeds are used 
as additions to other articles of food, to increase their sapidity 
and to promote a larger flow of saliva and gastric juice, and so 
assist digestion. Mustard, pepper, allspice, and vinegar are the 
principal condiments. Within certain limits they are not in- 
jurious, but the tendency in the use of all stimulants is to 



COOKING. 115 

exceed a healthful limit. Condiments, as well as other stimu- 
lants, should be used in moderation. 

COOKING. 

Much more attention than is generally given should be paid 
by physicians to the culinary art. The manner in which food is 
cooked has no little influence upon its digestibility. There can 
be no question that the extreme prevalence of functional indi- 
gestion in this country is almost exclusively dependent upon bad 
cooking. 

The various methods of cooking are boiling, frying, roast- 
ing, broiling, and baking. By either of these methods food can 
be cooked so as to be palatable as well as digestible ; on the other 
hand, the choicest article can be utterly spoiled and rendered 
unfit to be taken into the human stomach. It depends, therefore, 
not so much upon the method of cooking, as upon the knowledge 
and art of the cook. 

Boiling. — Meats of all kinds are rendered tender and di- 
gestible by boiling. In order to retain the flavor of meat, the 
water should be boiling when the meat is put into it. By the 
heat of the boiling water the albumen on the outside of the 
meat is coagulated and the juices and flavor retained within. 
After a few minutes the temperature of the water should be re- 
duced to 71° to 77° C. (160° to 170° F.), and maintained at that 
height until the meat is tender. By this process a much more 
savory piece of beef, mutton, or fowl can be obtained than where 
the meat is put into cold water and thus gradually heated. The 
latter method is, however, the proper one to be followed when 
good soup or broth is desired. 

In boiling vegetables, as much care is necessary as in boil- 
ing meat or fish. Potatoes and rice should be steamed, rather 
than boiled. 

The difficulty of obtaining a good cup of coffee, especially 
in the northern portion of the United States, illustrates the pre- 
vailing ignorance upon one of the simplest points in the art of 



116 TEXT-BOOK OF HYGIENE. 

cooking. Coffee should never be served in the form of a de- 
coction; that is to say, it should never be boiled. Properly made 
it is an infusion, like tea, which no one ever thinks of boiling. 
The difference between an infusion (especially if made by per- 
colation) and a decoction of coffee can only be appreciated by 
those who have enjoyed the one and endured the other. 

Frying. — Frying, if properly done, is really nothing less 
nor more than boiling in oil or fluid fat of some kind. Olive- 
oil is preferable, but is not essential ; butter, beef-drippings, lard, 
or probably cotton-seed oil may be substituted for it without 
disadvantage. The principle of frying depends upon the fact 
that the temperature of oil can be raised to such a height as to 
produce instant coagulation of the surface of meat, fish, or other 
object immersed in it while ho£ ; this film of coagulated albu- 
men imprisons the juices and flavors of the meat or fish, and pre- 
vents the fat entering and soaking the fibres with grease. Small 
fish or birds, properly fried, are justly regarded as delicacies by 
connoisseurs, but the process of saturating these objects with fat 
while gradually heating them produces a dish that is anything 
rather than grateful to the palate, or conducive to good digestion. 

Roasting. — The fame of " the roast beef of Old England" 
has passed into song, but, at the present day, beef and other 
meats are rarely roasted, either in this country or abroad. As 
Sir Henry Thompson well expresses it, 1 "the joint, which for- 
merly turned in a current of fresh air before a well-made fire, is 
now half stifled in a close atmosphere of its own vapors, very 
much to the destruction of the characteristic flavor of a roast." 
It is probable that the old method of roasting before an open fire 
produced not only the most savory, but likewise the most nu- 
tritious and digestible, meat. It is much to be regretted that the 
process has fallen so greatly into disuse. 

Broiling and Baking. — These methods of cooking are 
modifications of the process of roasting. Meats or fish, care- 
fully broiled or baked, preserve their natural juices and flavors 

1 Food and Feeding, p. 45. London, 1880. 



ALIMENTARY BEVERAGES. 117 

to a great extent, and retain their digestibility and nutritious 
properties. Of all methods of cooking these are probably best 
known and most satisfactorily applied in this country. 1 

ALIMENTARY BEVERAGES. 

The alimentary beverages may be divided into two classes, 
— those depending for their effects upon the alcohol they contain, 
and those whose active principles reside in certain alkaloids. 
They are used chiefly as digestive and nervous stimulants. 

BEVERAGES CONTAINING ALCOHOL. 

The physiological action of alcohol has been pretty fully 
worked out by Binz and his pupils, and by other experimenters. 
From these researches, it appears that the first effect of taking 
alcohol, sufficiently diluted, into the stomach, is to increase the 
flow of the saliva and gastric juice. This effect is probably re- 
flex, and results from a stimulation of nerve terminations in the 
stomach. The alcohol is rapidly absorbed, and is carried in the 
blood, without undergoing chemical change, to the nervous 
centres, lungs, and tissues generally. In the brain the alcohol 
probably enters into combination with the nervous tissue, 
modifying the normal activity of the various centres, either 
increasing the activity, if the alcohol is in small quantity (stim- 
ulating effect), or diminishing it if in larger quantity (depressing 
effect), or entirely suspending the activity of the centres, if in 
sufficiently large quantity (paralyzing effect). 

Alcohol stimulates the vasodilator nerves, causing dilata- 
tion of the smaller vessels ; in consequence of this the blood is 
largely sent to the periphery of the body ; the blood-pressure 
diminishes, and heat-radiation is increased. At the same time 
a portion of the alcohol is used up in the lungs in the produc- 
tion of animal heat, thus economizing the expenditure of fats 

1 Every one interested in the proper application of the principles of cookery should 
study the Lomb prize essay of the American Public Health Association, by Mary Hinman Abel, 
upon "Practical, Sanitary, and Economic Cooking." This little book can be obtained of Dr. I. 
A.Watson, Secretary, Concord, N. H. ; price, 25 cents. See, also, an essay on "The Art of Cook- 
ing," by Edward Atkinson, LL.D., in Popular Science Monthly, November, 1889. 



118 TEXT-BOOK OF HYGIENE. 

and proteids, and acting as a true respiratory food. Alcohol 
does not contribute nutritive material to the body ; it only per- 
mits that which is stored up to be saved for other uses, by fur- 
nishing easily-oxidizable (combustible) material for carrying on 
the respiratory process, and supplying animal heat. 

During the use of alcohol the excretion of urea is dimin- 
ished. This shows that waste of tissue is retarded in the 
body. 

Regarding the statement of some authorities that alcohol does 
not undergo any change in the body, but is excreted unchanged, 
Binz asserts 1 that alcohol appears in the urine only when 
exceptionally large quantities have been taken, and then in very 
small proportion. It is not excreted by the lungs, the peculiar 
odor of the breath being due not to the alcohol, but to the 
volatile aromatic ether, which is oxidized with greater difficulty, 
and so escapes unchanged. 

While alcohol produces subjectively an agreeable sensation 
of warmth in the stomach and on the surface of the body, the 
bodily temperature is not raised. The subjective sensation is 
due to the dilatation of the blood-vessels and the sudden hyper- 
emia of those parts. 

During fevers and other exhausting diseases, alcohol is 
invaluable to prevent waste of tissue and sustain the strength. 
It does not act merely as a stimulant to the circulation and 
nervous system, but, as above pointed out, saves the more stable 
compounds by furnishing a readily oxidizable respiratory food. 

When taken in small doses by healthy persons, alcohol 
diminishes the temperature by increasing heat-radiation. When 
large quantities are taken, the bodily temperature is reduced by 
diminishing heat production, as well as by increased radiation. 
This is shown in the condition known as dead-drunkenness, in 
which the temperature is sometimes depressed as much as 20 ° F. 
below the normal. Cases in which the temperature sank to 75°, 
78.8°, and 83° F. have been reported, with recovery in all cases. 

1 Realencyclopaedie d. ges. Heilk., Bd. I, p. 183. 



BEVERAGES CONTAINING ALCOHOL. 119 

The constant use of alcohol produces in all the organs an 
excess of connective tissue, followed by fatty degeneration and 
the condition known as cirrhosis. The organs most frequently 
affected are the stomach, liver, and kidneys. Serious pathological 
alterations also occur in the circulatory, respiratory, and nervous 
systems. 

Alcohol is not necessary to persons in good health. Prob- 
ably most persons, regardless of their state of health, do better 
without it. Its habitual use in the form of strong liquors is 
to be unreservedly condemned. The lighter wines and malt 
liquors, if obtained pure, may be consumed in moderate quanti- 
ties without ill effects. Even in these forms, however, the use 
of alcohol should be discouraged or, perhaps, prohibited in the 
young. 

Neither in hot nor in cold climates is alcohol necessary to 
the preservation of health, and its moderate use even produces 
more injury than benefit. The Polar voyager and the East 
India merchant are alike better off without alcohol than with it. 

It has long been a prevalent belief that the use of alcohol 
enables persons to withstand fatigue better than where no alcohol 
is used. A large amount of concurrent testimony absolutely 
negatives this belief. 1 

The predisposition to many diseases is greatly increased by 
the habitual use of alcohol. Sun-stroke, the acute infectious 
diseases, and many local organic affections attack, by preference, 
the intemperate. A recent collective investigation by the British 
Medical Association brought out the fact that croupous pneu- 
monia is vastly more fatal among the intemperate than among 
those who abstained from the use of alcoholic liquors. 

A further investigation by Baer has shown that the average 
expectation of life among users and dealers in alcoholic liquors 
is very much shortened. The following table gives a compara- 
tive view of the expectation of life in those who abstained from 
and those who used alcohol: — 

1 See Parkes' Hygiene, 6th ed., yol. i, pp. 315-327. 



120 



TEXT-BOOK OF HYGIENE. 
Table XIY. 

EXPECTATION OF LIFE. 



Age. 


Abstainers. 


Alcohol Users. 


At 25 


32.08 years. 
25.92 " 
19.92 " 
14.45 " 
9.62 " 


26.23 years. 
20.01 " 
15.19 " 


"35 

"45 


"55 


11.16 " 


"65 


8.04 " 



Table XV shows the influence of alcohol upon the mortality 
from various diseases : — 

Table XV. 





General Male Popu- 
lation (per cent.). 


Alcohol Venders 
(per cent.). 


Brain disease 

Tuberculosis 

Pneumonia and pleuritis .... 

Heart disease 

Kidney disease 

Suicide 

Cancer 


11.77 
30.36 
9.63 
1.46 
1.40 
2.99 
2.49 
22.49 


14.43 
36.57 
11.44 
3.29 
2.11 
4.02 
3.70 


Old age . 


7.05 



Alcohol as a beverage is consumed in the various forms of 
spirits, wines, and fermented liquors. The varieties of spirits 
most frequently used are brandy, whisky, rum, and gin. They 
are all procured by distillation. 

Brandy is distilled from fermented grape-juice, and has a 
characteristic aromatic flavor. When pure and mellowed with 
age it is the most grateful to the palate of all distilled spirits. 

Whisky is distilled from barley, rye, oats, corn, or potatoes. 
Each of these has a peculiar flavor, depending upon the par- 
ticular volatile ether formed during the distillation. Rye-, barley-, 
and corn- whiskies are almost exclusively used in this country. 



BEVERAGES CONTAINING ALCOHOL. 121 

Rum is distilled from molasses, and is a favorite ingredient 
in hot punches. It is often used with milk, eggs, and sugar, in 
the preparation of eggnog, a highly-nutritious, stimulating drink, 
which is often prescribed with great benefit in acute and chronic 
wasting diseases. 

Gin is an ardent distilled spirit, flavored with oil of juniper. 
It has a widely-spread popular reputation as a cure for kidney 
diseases, but is probably oftener responsible for the production 
of these diseases than for their cure. 

All of the above-mentioned liquors contain from 40 to 60 
per cent, of alcohol, and should always be diluted before being 
taken into the stomach, in order to prevent the local irritant 
effects of the alcohol upon the gastric mucous membrane. 

Wine is the product of the alcoholic fermentation of the 
saccharine constituents of fruits. Wine is usually derived from 
the grape, though other fruits may also furnish it. The stronger 
wines (sherry, port, madeira) contain from 16 to 25 per cent, 
of alcohol. The lighter wines (hock, red and white Bordeaux 
and Burgundy wines, champagnes) contain from 6 to 15 per 
cent, of alcohol. Some also contain considerable free carbonic 
acid (sparkling wines), of which the champagnes are types. The 
red and white Bordeaux and Rhine wines are probably the 
least objectionable of these beverages for habitual use. They 
contain sufficient alcohol to be lightly stimulant, have a pleasant 
acid flavor, and are least likely to produce the bad effects which 
usually follow in the wake of the habitual use of the stronger 
wines or ardent spirits. 

Preference should be given to the wines of domestic manu- 
facture, on account of the great probability of adulteration of the 
favorite brands of foreign wines. Many of the California, Vir- 
ginia, New York, and Ohio wines compare very favorably in 
flavor with those imported from abroad. The more reasonable 
cost of these domestic wines is also a point in their favor. 

Cider is the fermented juice of apples. It frequently pro- 
duces unpleasant gastric and intestinal disturbances when drunk, 



122 TEXT-BOOK OF HYGIENE. 

on account of the large quantity of malic acid contained in it. 
Although it is usually ranked as a " temperance drink," it is 
quite capable of causing intoxication when consumed in large 
quantities. 

Beer is the fermented extract of barley, mixed with a 
decoction of hops and boiled. It should be prepared only of 
malt, hops, yeast, and water, and should contain from 3 to 
4 per cent, of alcohol, 5 to 6 per cent, of extract of malt 
and hops, 2 to 4 per cent, of lactic and acetic acids, and from 
\ to ^ per cent, of carbonic acid. This ideal is, how- 
ever, rarely attained in the article sold by the liquor dealer. 
Numerous adulterations are practiced on the unsuspecting con- 
sumer. The hops are frequently substituted by aloes, calamus, 
and ginger, or by the more deleterious picric acid or picrotoxin. 
The rich brown color, sweetness, body, and creamy foam are 
produced by caramel and glycerin. The more expensive barley- 
malt is substituted by starch and rice, or grape-sugar and 
molasses. 

Ale, porter, and brown-stout are merely varieties of beer — 
some containing more sugar, others more extractive matter. 

Beer and its correlatives have considerable dietetic value, 
owing not merely to the alcohol they contain, but largely to the 
sugar and acids entering into their composition. When used to 
excess they often cause a considerable accumulation of fat. 

Kumys is the national beverage of the nomadic tribes of 
Tartary. It consists of the milk of mares which has undergone 
fermentation, partly lactic and partly alcoholic in character. 
Recently it has been introduced into Europe and also into this 
country, where it is made of cows' milk. It is a palatable, 
nutritious stimulant, and is often very useful as a dietetic article 
in disease. 

Kefyr is a product of the fermentation of milk which bears 
some resemblance to kumys. The following table (Table XVI) 
gives a comparative view of the composition of true kumys, the 
same prepared from cows' milk, and kefyr : — 



ALKALOIDAL BEVERAGES. 



123 



Table XYI. 





True Kumys 


Cows' Milk Kumys 


Kefvr 




(percent.). 


(percent.). 


(percent.). 


Proteids 


2.20 


2.35 


3.12 


Fats 


2.12 


2.07 


1.95 


Sugar 


1.53 


1.81 


1.62 


Lactic acid 


0.90 


0.40 


0.83 


Alcohol 


1.72 


1.90 


2.10 


C0 2 


0.85 


0.80 


0.92 



THE ALKALOIDAL BEVERAGES. 

The virtues of the alkaloidal beverages depend upon certain 
alkaloids which differ very little in their chemical composition 
or physiological effects, and upon certain volatile aromatic con- 
stituents of the various articles used. The principal articles 
employed in the preparation of these beverages are coffee, tea, 
chocolate, mate, and coca. It is estimated that 500,000,000 
people drink coffee, 100,000,000 tea, 50,000,000 chocolate, 
15,000,000 mate or Paraguay tea, and 10,000,000 coca. All 
of these are active nervous stimulants and retarders of tissue- 
waste. They are all liable to produce serious functional dis- 
turbances of the nervous, digestive, and circulatory systems if 
used to excess. Anaemia, digestive derangements, constipation, 
pale, sallow complexion, loss of appetite, disturbed sleep, nervous 
headaches and neuralgias are the most marked of these effects. 

On the other hand, when taken in moderate quantity, the 
alkaloidal beverages enable the consumer to withstand cold, 
fatigue, and hunger; they promptly remove the sensation of 
hunger, and diffuse a glow of exhilaration throughout the body. 

Coffee. — Coffee is the ripe fruit (seed) of the Caffea Arabica, 
a native of Arabia and Eastern Africa, but now cultivated in 
other tropical regions of the world. The fruit consists of two 
flat-convex beans, the flat surfaces of which are apposed to each 
other. These are enclosed in a fibrous envelope which is some- 
times used as a cheap substitute for the coffee-bean. 

The beverage, coffee, is an infusion of the roasted and 



124 TEXT-BOOK OF HYGIENE. 

ground bean in hot water. Its virtues depend upon the alkaloid, 
caffein, and an aromatic oil. The latter, being volatile, is driven 
off by long-continued heat. Hence boiled coffee lacks the 
grateful aroma of that which is made by simply infusing the 
ground bean in hot water. 

The great demand for coffee and its comparatively high 
price have caused it to be extensively adulterated and substituted 
by other natural and artificial products. Artificial coffee-beans 
have been made of clay, dough, or extract of chicory, colored 
to imitate the natural bean. The fraud is easily detected by 
placing the beans in water, when the artificial product soon falls 
to pieces, while the natural beans undergo no change of shape 
or consistence. 

Ground coffee as found in the stores is usually adulterated. 
The materials used for sophistication are : The grounds of coffee 
previously used, the roasted root of chicory, acorns, rye or barley, 
carrots, sunflower-seeds, caramel, and a number of articles of 
similar value, generally harmless. 

Tea. — The plants which furnish the tea-leaves are natives 
of China, Indo-China, and Japan. The tea-leaves contain a 
crystalline alkaloid, thein, identical in composition and proper- 
ties with caffein. The various sorts of tea found in the market 
(green and black teas, etc.) differ only in the relative proportion 
of tannin and thein contained in each. The aromatic principle 
also varies somewhat in the different sorts. 

Tea is adulterated to quite as great an extent as coffee, the 
leaves of various plants bearing more or less resemblance to tea- 
leaves being added to the latter. Much of the tea found in the 
market is colored artificially with Prussian blue and iron oxide. 
These additions are harmless, as they are not soluble in water. 

Chocolate. — Cocoa, from which chocolate is derived, is 
widely different in composition from tea and coffee. In addi- 
tion to its active principle, theobromin, which is identical with 
caffein and thein, it contains nearly 50 per cent, of fat, which 
renders it an article of high nutritive value. 



TOBACCO. 125 

Mate, or Paraguay tea, guarana, and coca are used to a 
considerable extent in some parts of South America as substi- 
tutes for coffee and tea. Their composition is not well known, 
but their effects are believed to depend upon alkaloidal princi- 
ples similar to caffein and thein. 

TOBACCO. 

Closely connected with the subjects treated in this chapter 
are the effects of the constant use of tobacco upon the human 
system The depressing effects of tobacco, due principally to 
the nicotine upon the nervous and digestive systems, have long 
been recognized. Recently, however, it has been found that 
very serious symptoms are produced upon the sense of vision by 
the constant or excessive use of tobacco. A special form of 
amaurosis, termed tobacco amaurosis, has been frequently noticed 
since attention was first called to it by Mackenzie. 

[The following additional works are recommended to the 
student : — 

Thos. K. Chambers, on Diet in Health and Disease. — Edward Smith, 
on Foods. — Forster, Ernahrung, in Pettenkofer u. Ziemssen's Handbuch 
der Hygiene. — Munk und Uffelmann, Die Ernahrung des Gesunden und 
Krankeu Mensehen. — I. Burney Yeo, Food in Health and Disease. — 
Kenwood, The Hygienic Laboratory, Part V.] 



QUESTIONS TO CHAPTER III. 

Food. 

What is a food ? What reasons have we for stating that the proxi- 
mate food principles must be combined in definite proportions to main- 
tain a normal degree of health? What are the alimentary principles 
necessary to man's existence ? Why do we need water ? What are the 
functions of the salts in our foods ? Is existence possible without a 
sufficient supply of nitrogenous food ? What is the relation of starch 
to fat as oxidizable food ? 

Are the proteid tissues of the body derived solely from the nitroge- 
nous foods? What are the sources of the body -fat? What tissues are 
mostly consumed during work? 

What is the relation between the proximate food principles, and 
what amount of each is necessary in the standard daily diet of a man at 
rest ? At moderate labor ? At hard work ? About what is the relation of 
nitrogenous to non-nitrogenous food ? Of nitrogen to carbon ? Is a 
standard diet necessarily an expensive one ? How may it be selected ? 

Why is a variety in the kind of food necessary ? Why may not a 
man live on nitrogenous foods, like meat, alone? Why not on non- 
nitrogenous food, like potatoes ? 

Has climate much influence upon the amount of food needed ? Has 
it upon the kind of food ? What kind of food is especially beneficial for 
a laboring man in cold weather ? Where do we find the proteid prin- 
ciples of food ? Where the fatty ? Where the carbohydrates ? The 
salts ? Why should only a moderate amount of food be taken, and why 
should it be properly prepared? What are some of the factors that 
increase the consumption of carbonaceous foods ? Does increased 
physical labor increase the demand for nitrogenous foods ? Which 
requires the most carbonaceous food, physical or mental labor? What 
maladies especially require fat-producing foods ? Has the food that a 
man eats anything to do with his moral character ? 

How may we classify food ? Name some of animal origin. From 
the vegetable kingdom. What is the function of condiments? Of 
stimulants ? 

Why is milk so nearly a perfect food ? What is the average compo- 
sition of cows' milk? What is the difference between human milk and 
cows' milk ? What other substitutes are sometimes used for human 
milk? 

(126) 



QUESTIONS TO CHAPTER III. 127 

What is cream ? What changes take place in milk upon standing 
for some time ? To what are these changes due ? What is made from 
the curd ? Has whey, or butter-milk, any food value ? 

What should be the specific gravity of milk? How is it deter- 
mined? What may lower the specific gravity? What may raise it? 
Has " skim-milk " a food value ? What is the objection to its sale ? 

How is milk frequently adulterated? How may this be detected? 
Why is the addition of water dangerous ? How else might the milk 
become infected ? 

May infectious diseases be transmitted from the cow toman through 
the milk? How may this danger of infection be avoided? What 
diseases are especially likely to be thus conveyed by the milk ? Give an 
account of the " Hendon cow disease." May the milk of animals suffer- 
ing from certain febrile diseases be dangerous to health ? Is the milk 
of cows fed on distilleiy or brewery refuse necessarily unwholesome ? 

How may the quality of a milk be determined ? What is a lacto- 
scope? What is a creamometer? What should be the minimum per- 
centage of cream? How may the rapid fermentation of milk be pre- 
vented? What is tyrotoxicon, and to what is it due? 

What is butter? What is its food value, and wh} T ? What change 
does it undergo in becoming u rancid "? How is it often sophisticated? 
What is oleo-margarine or butterine ? How is it made ? Is it unwhole- 
some, and is there any objection to its use if sold under its proper name? 
Upon what does the value of cheese depend ? Is it nutritious ? Why 
cannot large quantities be eaten at a time ? 

Which are the richest kinds of cheese? Is cheese often adulter- 
ated ? How may cheese be made more digestible ? What dangerous 
change may it undergo, and to what is this due ? 

"S^Why is meat such an important article of food? What is the per- 
centage of proteids and fats in the meats commonly used ? Upon what 
does the variation between these two principles depend ? Should meat 
be cooked and eaten immediately after death ? Should it be kept too 
long after death before being used ? Why should meat be always 
cooked ? What are the common methods of cooking ? Are beef-extracts 
really nutritious ? Are partially or wholly predigested preparations of 
meat nutritious ? What is the objection to their continued use ? 

What conditions may render meat unfit for food ? How may- the 
various parasites in meat be destroj^ed ? What animals are apt to be 
infested with trichinae ? In what two forms are the trichinae found in ani- 
mals ? How do they gain access to the muscles ? May salted or smoked 



128 QUESTIONS TO CHAPTER III. 

meat contain living trichinae ? Of what parasite is the Gysticercus cellu- 
losa a transition form? 

What may be the result of using partially-decomposed meat or fish ? 
To what are the serious results due ? How are the ptomaines produced ? 
What is their probable chemical nature ? What peculiar idiosyncrasy 
have some people regarding shell-fish ? What infectious diseases may be 
transmitted to human beings by the consumption of infected meat ? 
When and by whom should meat be inspected ? 

Why are eggs so highly valued for food ? In which form are eggs 
most digestible ? Why do eggs undergo putrefaction so readily ? 

What cereals are used in making bread ? What part of the grain 
contains the greater proportion of proteids? Is all the gluten to be 
found in the bran ? Which flours are most nutritious and which most 
digestible? What are some of the characteristics of good bread? To 
what is the porosity due, and how is it produced ? How may the loss 
of starch by fermentation be avoided ? How is flour often adulterated ? 
Why is alum added to flour ? What disease of grain may be harmful to 
the health of the users ? 

What is the chief constituent of potatoes and rice ? In what prin- 
ciple are the leguminous foods especially rich ? Wherein is the chief 
value of green vegetables ? Why are fruits and nuts valuabe as articles 
of diet ? What rule should be observed regarding the use of condiments ? 

Why should physicians know considerable about cooking? What 
are the various methods of cooking? What is the effect of boiling 
upon meats ? What points are to be observed in the boiling of meat ? 
In the making of soups, etc. ? What valuable principle is lost if vege- 
tables are boiled too long ? What is the secret in making good coffee ? 
What is frying? How should it be done ? How should meats be roasted ? 
Why are broiling and baking generally satisfactory processes? 

Into what two classes may alimentary beverages be divided ? For 
what are those of the second class used ? What is the physiological effect 
and action of alcohol upon the nerve-centres ? Upon the circulation ? Is 
it changed before absorption ? Does it nourish the body ? Does it supply 
heat ? Does it raise the body -temperature ? What effect has it on heat- 
production and heat-radiation? On tissue waste? How is it excreted ? 
What effect have small amounts of alcohol upon digestion ? What patho- 
logical changes are brought about by the constant use of alcohol? Is it 
necessary or beneficial to persons in good health ? Why is it so valuable 
in fevers and wasting diseases? Does it enable persons to withstand 
fatigue ? To what diseases is the predisposition increased by the habitual 
use of alcohol? What effect has it upon the expectation of life and 



QUESTIONS TO CHAPTER III. 129 

upon the mortality from various diseases ? If used habitually, what forms 
should be chosen ? What is the difference between spirits, wines, and 
malt liquors? What is brandy? From what is whisky made? How 
much alcohol do the various spirits contain, and what rule should be 
observed regarding their use ? What percentage of alcohol do the various 
wines contain? Which are the least objectionable for habitual use? 
What can be said regarding the domestic wines? To what disturbances 
may cider give rise, and why ? From what articles alone should beer be 
made ? How much alcohol should it contain ? With what substances is it 
often sophisticated ? Have beer, ale, etc., a dietetic value, and wiry ? What 
may be the result when beer is used to excess ? What is kumyss and 
kefyr ? Why are they valuable in sickness ? How much alcohol does each 
contain? Upon what do the virtues of the alkaloidal beverage depend? 
What are the principal articles employed in their preparation ? What 
is the physiological action of all these substances ? What are some of 
the effects if they are used to excess? What is their effect when used in 
moderation ? May they be used as substitutes for alcohol ? 

What is coffee, and what alkaloid does it contain? What else does 
it contain that gives value to the beverage? How is coffee adulterated, 
and how may fraud be detected? What is tea, and what alkaloid does 
it contain ? How may it be adulterated ? Why is cocoa of greater food 
value than tea or coffee? What is its active principle, and what is its 
relation to thein and caffein ? What is the difference between cocoa and 
chocolate ? What are the effects of tobacco upon the human system, and 
to what are they due ? 






CHAPTER IV. 

Soil. 

Hippocrates treated at length, in one of his works, of the 
sanitary influences of the soil. Others of the older writers, 
especially Herodotus and Galen, called attention to the same 
subject, and Yitruvius, the celebrated Roman architect, who 
flourished about the beginning of the Christian era, taught that 
a point of first importance in building a dwelling was to select a 
site upon a healthy soil. 

From this time until the beginning of the eighteenth cen- 
tury, very little of value is found in medical literature bearing 
upon this subject. In 1717, however, Lancisi published his 
great work on the causes ' of malarial fevers, in which he laid 
the foundation for the modern theory of malaria, and pointed 
out the relations existing between marshes and low-lying lands 
and those diseases by common consent called malarial. Other 
authors of the eighteenth and the early part of the nineteenth 
centuries refer to the connection between the soil and disease, 
but exact investigations have only been made within the last 
thirty years. 

When it is considered that the air that human beings 
breathe, and much of the water they drink, are influenced in 
their composition by the matters in the soil, the great importance 
of possessing a thorough knowledge of the physical and chemical 
conditions of the soil becomes evident to every one. 

PHYSICAL AND CHEMICAL CHARACTERS OF THE SOIL. 

In the hygienic, as in the geological sense, rock, sand, clay, 
and gravel are included in the consideration of soils. 

The soil, as it is presented to us at the surface of the earth, 

(131) 



132 TEXT-BOOK OF HYGIENE. 

is the result of long ages of disintegration of the primitive 
rocks by the action of the elements, of the decomposition of 
organic remains, and, possibly, of accretions of cosmical dust. 
The principal factor, however, is the action of water upon rock, 
in leveling the projections of the earth's surface produced by 
volcanic action. 

Soils vary considerably in physical and chemical constitu- 
tion. A soil may, for example, consist exclusively of sand, of 
clay, or of disintegrated calcareous matter. Other soils may 
consist of a mixture of two or more of these, together with 
vegetable matter undergoing slow oxidation. In forests, a layer 
of this slowly-decomposing vegetable matter of varying thick- 
ness is found, covering the earthy substratum. This organic 
layer is called humus, and when turned under by plough or 
spade, and mixed with the sand or clay base, it constitutes the 
ordinary agricultural soil. 

THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 

The interstices of the soil are occupied by air or water, or 
by both together. The soil's atmosphere is continuous with, 
and resembles in physical and chemical properties, that which 
envelops the earth. Its proportion to the mass of the soil 
depends upon the degree of porosity of the soil, and upon the 
amount of moisture present. In a very porous soil, such as, for 
example, a coarse sand, gravelly loam, or coarse-grained sand- 
stone, the amount of air is much greater than in a clayey soil, 
granite, or marble. So, likewise, when the soil contains a large 
proportion of water, the air is to this extent excluded. The 
porosity of the various soils, as evidenced by the amount of air 
contained in them, is much greater than would, at first thought, 
be supposed. Thus it has been found that porous sandstone 
may contain as much as one-third of its bulk of air, while the 
proportion of air contained in sand, gravel, or loose soil may 
amount to from 30 to 50 per cent. 

The ground-air is simply the atmospheric air which has 



THE ATMOSPHERE OF THE SOIL, OR GROUND- AIR. 133 

penetrated into the interstices of the soil and taken part in the 
various chemical decompositions going on there. In consequence 
of these chemical changes the relative proportions of the oxygen 
and carbonic acid in the air are changed — oxygen disappearing 
and giving place to carbon dioxide. It is well known that 
during the decay of vegetable matter in the air carbon dioxide 
is formed; one constituent of this compound, the carbon, being 
derived from the vegetable matter, while the oxygen is taken 
from the air. Hence, if this action takes place where there is 
not a very free circulation of air, as in the soil, the air there 
present soon loses its normal proportion of oxygen, which enters 
into combination with the carbon of the vegetable matter to 
form carbon dioxide. 

Thirty years ago, MM. Boussingault and Levy, two dis- 
tinguished French chemists, examined the air contained in 
ordinary agricultural soil, and found that the oxygen was 
diminished to about one-half of the proportion normally present 
in atmospheric air, while the carbon dioxide was enormously 
increased. The exact results obtained by Boussingault and 
Levy were as follow: — 

In 100 volumes of ground-air there were 10.35 volumes 
of oxygen, 79.91 volumes of nitrogen, 9.74 volumes of carbon 
dioxide. In atmospheric air, on the other hand, there are in 
100 volumes 20.9 volumes of oxygen, 79.1 volumes of nitrogen, 
0.04 volume, or about ^V of 1 per cent, of carbon dioxide. 

In spite of the striking results obtained by these two 
chemists, very little attention was paid to them by sanitarians, as 
very few seemed to have any clear notion of the relations exist- 
ing between the motions of the air above-ground and that under- 
ground. 

In 1871, however, Professor von Pettenkofer, of Munich, 
published the results of his own examinations into the constitu- 
tion and physical conditions of the ground-air, and the relations 
of the latter to the propagation of epidemic diseases. These re- 
searches, which created a wide-spread interest in the subject, 



134 TEXT-BOOK OF HYGIENE. 

were extended by other observers in- all parts of the world. 
These observers, prominent among whom were Professors Fleck, 
Fodor, and Soyka, in Germany ; Drs. Lewis and Cunningham, 
in India ; Prof. William Ripley Nichols, in Boston ; and Sur- 
geons J. H. Kidder and S. H. Griffith, of the U. S. Navy, in 
Washington, demonstrated that the increase of carbon dioxide 
in the ground-air is due to increased vegetable decomposition 
and to lessened permeability of the soil. A permeable, that is 
to say, a sandy or gravelly soil is likely to contain less carbon 
dioxide in its atmosphere than a dense, less permeable clay, 
although the amount of decomposition going on and the pro- 
duction of carbon dioxide in the former may considerably ex- 
ceed the latter. In the loose, sandy soil the circulation of the 
air is less obstructed, and the carbon dioxide may easily escape 
and be diffused in the superincumbent air, while the close-pored 
clay imprisons the carbon dioxide and prevents or retards its 
escape into the air above. 

The disappearance of oxygen from the ground-atmosphere 
is coincident with the production of an equivalent amount of 
carbon dioxide. It appears from this that in the soil an ox^ 
idation of carbonaceous substances takes place, the product of 
which is found in the excess of carbon dioxide in the ground-air. 

Professor Nichols has found the proportion of carbon di- 
oxide in the air taken from a depth of 3 metres below the 
surface in the "made-land" of Boston to amount to 21.21 per 
thousand, the observation having been made in August. In 
December, at a depth of 2 metres, the proportion was 3.23 per 
thousand. Fodor, in Buda-Pesth, found the proportion of carbon 
dioxide to be 107.5 per thousand (over 10 per cent.), the air 
having been taken from a depth of 3 metres. 

The ground-air also teems with micro-organisms of various 
kinds, these being occasionally pathogenic. While in the great 
majority of instances the micro-organisms found are ordinary 
mold or fermentation fungi and bacteria of decay and putrefac- 
tion, disease-producing bacilli have also been observed in a 



THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 135 

number of instances. Among the latter are the bacillus of 
tetanus (Nicolaier), of anthrax (Frank), of malaria (Klebs and 
Tommasi-Crudeli), 1 of malignant oedema (Koch and GafTky), 
and of typhoid fever (Tryde). 

It may not be inappropriate to refer here to the claim of 
Professor Domingos Freire, of Brazil, to the discovery of the 
germ of yellow fever in the soil of a burial ground near Rio 
Janeiro. The exhaustive investigations of Surgeon-General 
G. M. Sternberg, of the U. S. Army, under the direction of the 
government, have disposed effectually of the claims and pre- 
tensions of the Brazilian scientist, and established the fact that 
Freire's organism has no pathological significance whatever, — 
at all events, that it has no relation to yellow fever. 

Cholera bacilli have not been found in the soil, but C. 
Frankel has shown experimentally that they can grow and 
multiply in the soil at various depths. At a depth of 1^ 
metres their development was constant and progressive 
throughout the year. 

When the soil is dry, these organisms may be carried hither 
and thither in the movements of the ground-air, and thus infect 
the air of contiguous localities, or be transported to a distance. 

Movements of the ground-atmosphere are principally due 
to differences of pressure and temperature in the air above- 
ground. Owing to such differences the air from the soil fre- 
quently permeates houses, entering from cellars or basements. 
In winter, when the air of houses is very much more heated 
(and consequently less dense) than the air out-of-doors, 
the difference of pressure thus caused draws the ground-air up 
through the house, while the cold, external atmosphere pene- 
trates the soil and occupies the place of the displaced ground- 
air. 2 A similar effect occurs in consequence of heavy rains. 

1 While the pathogenic significance of Klebs' bacillus malarice is not generally accepted, 
it is thought proper, for the sake of completeness, to include it among the organisms sometimes 
found in the soil. 

a It is, of course, not strictly correct to say that the air is drawn up through the house 
by the diminution of pressure ; it being rather forced out of the soil by the colder and denser 
outside air ; but the phrase is sufficiently exact and will be readily understood. 



136 TEXT-BOOK OF HYGIENE. 

The water fills up the interstices of the soil near the surface, and 
forces the ground-air out at points where the pores remain open. 
These places are the dry ground under buildings, where the air 
escapes and passes through floors and ceilings into the house 
above. Heavy rains may thus be the cause of pollution of the 
air in houses. The greater the porosity of the soil, the more 
likely is this to happen. This pollution of the house-air may 
be prevented by having impervious floors and walls to cellars 
and basements, or by interposing a layer of charcoal between 
the ground and the floor of the house. The latter does not 
prevent the passage of the ground-air, but the charcoal layer 
absorbs or arrests the noxious matters, — filters the ground-air, 
as it were. 

In the spring and early summer the ground being colder 
than the air above it, and the ground-air consequently heavier 
and denser, the latter is not easily displaced. It is, perhaps, 
due to this fact that those infectious diseases which are proba- 
bly dependent upon the movements of the ground-air are less 
prevalent in the spring and early summer than in the latter 
part of the summer, autumn, and early winter. In the autumn 
the ground-air being warmer than the air above ground is easily 
displaced by the latter and forced out into the streets and houses 
to be inspired by men and animals. The same conditions may 
explain the greater likelihood of infection at night, which is 
proven for such diseases as malarial and yellow fevers. The 
colder outside air penetrates the interstices of the soil and forces 
out the impure ground-air. 

The researches of Fodor have demonstrated that the pro- 
portion of carbon dioxide in the ground-air may be taken as an 
approximative measure of the impurity of the soil whence the 
air is taken. The influence of the permeability of the soil, as 
before pointed out, must, however, not be overlooked in esti- 
mating the signification of the carbon dioxide. Fodor has 
shown that the proportion of carbon dioxide in the ground-air, 
and consequently the amount of organic decomposition, is 



THE ATMOSPHERE OF THE SOIL, OR GROUND- AIR. 137 

greatest in July and least in March. That the carbon dioxide 
is derived from the decomposition of vegetable matter has been 
proven by Pettenkofer. This observer examined specimens of 
air brought from the Lybian desert, and found that the propor- 
tion of carbon dipxide in the ground-air was exactly the same 
as in the air collected above-ground. There being no vegetable 
growth in the desert there can, of course, be no vegetable 
decomposition going on in the soil. 

The excess of carbon dioxide in the ground-air is an indi- 
cation of the deficiency of oxygen, as has been shown. The 
air at a depth of 4 metres below the surface was found to 
contain only from 7 to 10 per cent, of oxygen — one-half to one- 
third of the normal proportion. Many basements occupied by 
people as living-rooms extend from 1 to 3 metres under-ground, 
and hence are liable to be supplied with an atmosphere approach- 
ing in impurity that just mentioned. It requires no very vivid 
imagination to appreciate the dangers to health that lurk in such 
habitations. 

THE WATER OF THE SOIL, OR GROUND-WATER. 

At a variable depth below the surface of the ground, a 
stratum of earth or rock is found through which water passes 
with difficulty, if at all. Above this there is a stratum of water 
which moves from a higher to a lower level, and which varies 
in depth at different times according to the amount of precipita- 
tion (rain- or snow- fall), and according to the level of the nearest 
body of water toward which it flows. This stratum of water 
is termed the ground-water, and has within the last few years 
assumed considerable importance from its apparently close rela- 
tions to the spread of certain of the infectious diseases. The 
direction of horizontal flow of ground-water is always toward 
the drainage-area of the district. Thus, it is usually toward 
lakes, rivers, or the sea. Rains, or a rise in the river, cause a 
rise in the ground-water, while long-continued dry weather, or 
a low stage of the river which drains off the ground-water, 



138 TEXT-BOOK OF HYGIENE. 

causes a fall in the latter. On the sea-coast the ground- water 
oscillations probably correspond with the tides. The writer is 
not aware of any observations made to determine this point, 
with the exception of a single instance mentioned by Dr. De 
Chaumont. In Munich, where the ground-water flows toward 
the river Isar, which divides the city, it has been found that the 
annual range or oscillation (the difference between the highest 
and lowest level during the year) is 3 metres, while the hori- 
zontal movement amounts to 5 metres per day. In Buda-Pesth 
the annual range was found by Fodor to be less than 1 metre, 
while in some portions of India it amounts to more than 12 
metres. As it is from the ground-water that the greater portion 
of the supply of drinking-water in the country and in villages 
and small towns is drawn, it becomes at once manifest how 
important it is to prevent, as far as possible, pollution of this 
source. Cess-pools and manure-heaps and pits, of necessity, 
contaminate the soil and also ground- water for a distance below 
and around them, and such water is clearly unfit for drinking 
and other domestic purposes. Hence, the reason why wells 
should not be placed too near privies and manure-heaps or pits 
becomes apparent. 

Between the level of the ground-water, or that portion of 
the soil where its pores are entirely occupied by the water — 
where, in other words, the ground is saturated — and the surface, 
is a stratum of earth more or less moist ; that is to say, the 
interstices of the soil are partly filled with water and partly with 
air. It is in this stratum that the processes of organic decay or 
putrefaction are most rapidly going on, in consequence of which 
the pollution of the ground-air occurs. The oxidation of non- 
nitrogenous matter in the soil results in the formation of carbon 
dioxide. On the other hand, nitrogenized compounds are 
oxidized into nitric acid and nitrates. When, however, putre- 
faction occurs, nitrous acid, or nitrites and ammonia, are formed, 
the oxidation not proceeding far enough to result in nitric acid. 

Recent observations seem to show that these processes of 



THE WATER OF THE SOIL, OR GROUND- WATER. 139 

decomposition are initiated and kept np by minute organisms 
termed bacteria, just as fermentation in liquids containing sugar 
can only take place in the presence of the yeast-plant. It has 
been found that when non-putrefactive decomposition goes on, 
there are always present multitudes of one variety of these 
minute organisms; while if putrefactive decomposition is going 
on, a number of other varieties of these organisms are present. 
Just as, when a fermenting liquid becomes putrid, the yeast-plant 
disappears and its place is taken by the ordinary bacteria of putre- 
faction, so in the soil, if the access of oxygen, which is necessary 
to the life of the bacteria of decay, is prevented, these organisms 
die and are succeeded by the organisms of putrefaction. It has 
been found that in a soil saturated with water the bacteria of decay 
cannot live, while those of putrefaction may flourish, because 
these latter organisms can sustain life and develop in the 
absence of oxygen. Professor Fodor's researches indicate that 
the most prominent organism of non-putrefactive decomposition 
or decay is that which is termed by Cohn bacterium lineola ; and 
that the bacterium termo is the principal organism of putrefaction. 

DISEASES SPREAD BY SOIL IMPURITIES. 

Given now an area of soil, say the ground upon which a 
house or city is built, with a moist stratum in which the pro- 
cesses of decay are active, and imagine a rise in the ground- 
water. The ground-air, charged with carbon dioxide and other 
products of decomposition, is forced out of the pores of the soil 
by the rising ground-water, and escapes into the external air, 
or through cellars and basements into houses, and may there 
produce disease. But the saturation of the soil with water pre- 
vents the further development of the bacteria of decay, and this is 
checked, or putrefaction may take place. If now the ground- 
water sinks to its former level or below, the processes of decay 
again become very active in the moist stratum, and large quan- 
tities of carbon dioxide and other inorganic compounds are 
produced. If the germs of infectious or contagious diseases 



140 TEXT-BOOK OF HYGIENE. 

have been introduced into the soil, they also multiply and may 
escape with the movements of the ground-air into the external 
atmosphere, and there produce their infective action. This, it is 
held by Pettenkofer and his followers, is what actually occurs in 
cholera and typhoid fever. Professor DeChaumont has laid 
down the rule that a soil with a persistently low stage of ground- 
water, say 5 metres below the surface of the ground, is healthy; 
a persistently high stage of ground- water, less than 1^ metres 
below the surface, is unhealthy; while a fluctuating level of the 
ground-water, especially if the changes are sudden and violent, 
is very unhealthy. This would lead us to expect that places 
where this fluctuation is very great would show a large mortality 
from such diseases as are attributed to impurities in the soil. 
And this we find especially true in India. In certain localities 
in India, cholera, for example, is endemic ; that is to say, the 
disease is never entirely absent in such localities. Calcutta is 
one of these places. The rainy season begins about the first of 
May and continues until the end of October. During the next 
six months there is very little rain. It is fair to assume that 
the ground-water rises during the rainy season and checks decay 
and the multiplication of the germs of the disease in the soil, 
and that these processes become more active as the dry season 
advances and the ground-water level falls. If we note the 
death-rate from cholera in Calcutta it will be found that it bears 
a distinct relation to the movement of the ground-water. The 
deaths from cholera begin to increase from October and reach 
their height in April. Dr. Macpherson, who has written a very 
elaborate history of Asiatic cholera, shows this relation very 
clearly. For twenty-six years the average rain-fall was 157 cen- 
timetres. From May to October 1 42 centimetres fell, while the 
remaining 15 centimetres fell from November to April. The 
average number of deaths from cholera annually was 4013. 
Of these, 1238 died in the rainy season, while 2775, nearly 
three-fourths, died during the period of dry weather. 

In the cholera epidemics of 1866 and 1873 in Buda-Pesth, 



DISEASES SPREAD BY SOIL IMPURITIES. 141 

the same relations existed between the ground-water and the 
cholera. As the level of the ground-water rose the cholera 
diminished, while the disease increased upon the sinking of the 
ground-water. Exactly the same behavior was exhibited by the 
disease in Munich in 1873. 

There seems good reason to believe that typhoid fever is 
propagated in consequence of movements of the ground-water, 
in the same way as above explained for cholera. This does not 
exclude the infection of drinking-water by the disease-germ, 
since much of the drinking-water used, as before stated, is drawn 
from the ground-water. Pettenkofer, Buhl, and Virchow have 
shown that the death-rate from typhoid fever has a distinct and 
definite relation to the ground-water oscillations. This has been 
incontestably proven for two cities, Munich and Berlin. When 
the level of the ground- water is above the average, typhoid fever 
decreases; when it is below the average, the number of cases 
becomes greater. Dr. H. B. Baker has demonstrated that the 
fluctuation of the ground-water level in the State of Michigan 
is similarly followed by a change in the morbility and mortality 
from typhoid fever. 1 Hence, it may be regarded as an established 
law that the rise and fall of the ground-water bears *a definite 
relation to the morbility rate of typhoid fever. 

Nearly thirty years ago Dr. Henry I. Bowditch, of Boston, 
called attention to the frequent connection between cases of 
pulmonary consumption and dampness of the soil upon which 
the patients lived. After a very extended and laborious investi- 
gation Dr. Bowditch formulated these two propositions: — 

" First. — A residence in or near a damp soil, whether that 
dampness be inherent in the soil itself or caused by percolation 
from adjacent ponds, rivers, meadows, or springy soils, is one of 
the principal causes of consumption in Massachusetts, probably 
in New England, and possibly other portions of the globe. 

" Second. — Consumption can be checked in its career, and 

1 The Relation of the Depth of Water in Wells to the Causation of Typhoid Fever, 
Public Health, vol. x, p. 184-213. 



14 '2 TEXT-BOOK OF HYGIENE. 

possibly — nay, probably — prevented in some instances by atten- 
tion to this law." 1 

Dr. Buchanan, of England, about the same time showed 
that the thorough drainage of certain English cities had mark- 
edly diminished the deaths from consumption in the drained 
cities. So far as the writer is aware, not a single fact has been 
established which militates against the law laid down by Dr. 
Bowditch, and so strongly supported by the statistical researches 
of Dr. Buchanan, yet hardly any notice has been taken of these 
results by physicians. Few know anything of them, and still 
fewer seem to have made practical use of such knowledge in 
advising patients. As corroborative of the views of Dr. Bow- 
ditch, the rarity of consumption in high and dry mountainous 
districts or plateaus may be cited. 

A recent study of the topographical distribution of con- 
sumption in the State of Pennsylvania, by Dr. William Pepper, 
apparently confirms Dr. Bowditch's conclusions in nearly every 
particular. It is now known that the direct cause of consump- 
tion is the bacillus tuberculosis, discovered by Dr. Robert Koch. 
The relation between soil-moisture and the increase of consump- 
tion will probably be found in the more favorable conditions 
of development of the tubercle bacillus furnished by a moist 
medium. 

DISEASES OF ANIMALS PROBABLY DUE TO SIMILAR CONDITIONS OF 

THE SOIL. 

The modern study of the sanitary relations of the soil is 
still in its infancy. Whatever definite knowledge has been 
gained relates merely to physical or chemical conditions of the 
soil and its atmosphere and moisture, or possibly the relations 
of these to the spread of certain diseases in human beings. But 
there is, perhaps, a wider application that may be made of such 
knowledge than has been heretofore suggested. The domestic 
animals which form such a large portion of the wealth of this 

» Consumption in New England and Elsewhere, 2d ed., p. 87. Boston, 1866. 



DISEASES OF ANIMALS DUE TO SIMILAR CONDITIONS OF SOIL. 143 

country — horses, cattle, sheep, and hogs — are liable to infectious 
and contagious diseases, as well as are human beings, and many 
millions of dollars are lost annually by the ravages of such 
diseases. Now, from what is known of such diseases as splenic 
fever among cattle, and of the so-called swine plague, it does 
not appear improbable to the writer that the source of infection 
is a soil polluted by the poisonous germ of these diseases, just 
as it seems demonstrated that cholera and typhoid fever and 
possibly malarial fevers are so caused. The laborious investiga- 
tions of M. Pasteur in France have shown that the cause of 
splenic fever, when once introduced into a locality, will remain 
active for months, and even years, and it seems probable that a 
study of the soil in its relations to the diseases of domestic 
animals is a subject to which attention may profitably be 
given. 

It is well known that milch-cows frequently suffer from a 
disease identical in its nature with consumption in human 
beings. It is believed by many that the milk of such animals 
is not only unfit for food by reason of its poor quality, but that 
it may convey the disease to human beings when used as food. 
The observations of Bowditch and Buchanan, quoted above, 
show that consumption in man may be, and doubtless is, 
frequently caused by soil-wetness. It seems probable that the 
same cause should produce similar effects in the lower animals, 
and it is the writer's firm conviction that an examination into 
the circumstances under which cows become attacked by con- 
sumption would prove this probability a fact. 

DRAINAGE. 

In many soils drainage is necessary in order to secure a 
constant level of the ground-water at a sufficient depth below 
the surface. Drainage and sewerage must not be confounded 
with each other. Drainage contemplates only the removal of 
the ground-water, or the reduction of its level, while sewerage 
aims to remove the refuse from dwellings and manufactories, 



14-i TEXT-BOOK OF HYGIENE. 

including excrementitious matters, waste-water, and other 
products, and in some cases the storm-water. 

Sewers should never be used as drains, although for 
economy's sake sewer- and drainage- pipes may be laid in the 
same trench. Sewer-pipe must be perfectly air-tight and water- 
tight to prevent escape of its liquid or gaseous contents into the 
surrounding soil and rendering it impure. Drainage-pipe, on 
the other hand, should be porous and admit water freely from 
without. Escape of the contents of the drain-pipe into the 
surrounding soil will not produce any pollution of the latter. 

The best material for drains is porous earthenware pipe, or 
the ordinary agricultural drain-tile. Coarse gravel or broken 
stones may also be used, and prove efficient if the drains are 
properly constructed. Referring again to the aphorism of 
Professor DeChaumont, that a persistently low ground-water, 
say 5 metres down, or more, is healthy; that a persistently high 
ground- water, less than \\ metres from the surface is unhealthy; 
and that a fluctuating level, especially if the changes are sudden 
and violent, is very unhealthy, the necessity appears obvious 
that in the construction of drainage-works the drains should be 
placed at a sufficient depth to secure a level of the ground-water 
consistent with health. This depth should never be less than 
3 metres, and, if possible, not less than 5 metres. Care must be 
taken that the outflow of the drain is unobstructed, in order 
that the soil may be kept properly dry at all times. 

In the absence of a proper mechanical system of drainage, 
the planting of certain trees may efficiently drain the soil. It 
has been found that the eucalyptus tree has produced drying of 
the soil when planted in sufficient numbers in marshy land. 
The roots absorb a prodigious quantity of water, which is then 
given off by evaporation from the leaves. Sunflower-plants have 
a similar effect upon wet soils. 



QUESTIONS TO CHAPTER IV. 

The Soil. 

Why is it necessary to possess a knowledge of the physical and 
chemical conditions of the soil? What substances are included in the 
consideration of soils ? Of what is the surface soil composed ? How 
do soils vary in composition, physically and chemical^ ? 

What occupies the interstices of the soil? Upon what does the 
proportion of air in the soil depend ? Is this proportion comparatively 
great or small ? What relation has the soil-air to the atmospheric air, 
and what causes the difference in composition ? In what way does the 
soil-air differ from the atmospheric air? Has the soil-air any definite 
composition ? What are the factors governing the variation in composi- 
tion ? What kind of a soil will be likely to contain most carbon dioxide 
and least oxygen ? What does this indicate ? What micro-organisms 
are always to be found in the soil-air? What pathogenic organisms 
ma}' also make the soil and soil-air their habitat ? How may these be 
carried from place to place ? To what are movements of the ground-air 
due? How may this soil-air gain access to our houses, and what meas- 
ures should be taken to prevent its entrance? When is the danger 
greatest ? Why are certain infectious diseases less prevalent in spring 
and early summer than in autumn? Why is there greater danger of 
infection from these diseases at night than in the day-time? Is the 
carbon dioxide of the soil-air a measure of the impurity of the soil ? 
What causes the excess of carbon dioxide ? When is the proportion of 
carbon dioxide greatest ? Why are living-apartments below the surface 
01 the ground very apt to be unhealthy ? 

What is meant by the term " ground-water" ? Where is it to be 
found ? Has it a definite current ? In what direction is the flow ? 
Upon what does the level of the ground-water depend ? What class of 
the population derive their drinking-water largely from the ground- 
water ? What are some of the sources of contamination of the ground- 
water ? What are some of the deductions to be made accordingly ? 

In what part of the soil do the processes of organic decay and putre- 
faction occur most readily ? What are the causes of these processes ? 
What are some of their products ? What is the distinction between 
non-putrefactive decomposition or decay and putrefaction ? 

10 (145) 



146 QUESTIONS TO CHAPTER IV. 

How majr disease be spread by the rise and fall of the ground-water? 
What two infective diseases are especially apt to be transmitted in this 
way ? Give instances that tend to prove this. Upon what other dis- 
ease has a damp soil a directly causative influence ? What diseases of 
animals are likely to be influenced in a similar manner ? How deep 
below the surface should the soil-water persistently be that the soil may 
be healthy? What effect upon health has a suddenly and markedly 
fluctuating soil-water? Is a soil with its water persistently near the 
surface apt to be healthy ? 

What do we mean by drainage, and what is its object and function ? 
What is the difference between it and sewerage? How should drains be 
laid ? What is the best material for drains ? What precautions must 
be observed in the laying of drains ? How may the surplus water be 
taken from the soil otherwise than by drains ? 



CHAPTER V. " 
Removal of Sewage. 

In all larger communities certain arrangements are neces- 
sary to secure a prompt and efficient removal of excreta and 
the refuse and used water of households and manufacturing 
establishments, the sweepings of streets, and rain-water. 

The total quantity of excrementitious products — faeces and 
urine — for each individual, including men, women, and children, 
has been estimated by Professor von Pettenkofer as 90 grammes 
of faecal and 1170 grammes of urinary discharge daily. This 
would give for a population of 1000 persons 34,000 kilogrammes 
of faeces and 428,000 litres of urine per year. If to this is 
added a minimum allowance of 159 litres of water per day to 
each individual, a complete sewerage system for a population 
of 1000 persons would require provision for the discharge of 
160,000 litres of sewage passing through the sewers every day. 
In this estimate storm-water and such accessory feeders of the 
sewage are omitted. 

The organic matters contained in sewage, even if free from 
the specific germs of disease, give rise to noxious emanations, 
which, when inhaled, probably produce a gradual depravement 
of nutrition that renders the system an easier prey to disease. 
For this and other reasons it is important that such measures be 
adopted as will secure the removal of sewage matters from the 
immediate vicinage of houses as quickly as possible after they 
have been discharged. 

The impregnation of the soil with sewage produces a con- 
tamination of ground-air and ground-water, which may become 
a source of grave danger to health. By polluting the ground- 
water it eventually vitiates the well-water, which is nearly always 
derived from that source. 

(147) 



14:8 TEXT-BOOK OF HYGIENE. 

The system of removal of excrementitious matters which 
any community will adopt depends to a considerable extent upon 
financial considerations. Although the sanitarian must insist 
upon the pre-eminent importance of the cause of public health, 
his suggestions will receive little attention from municipal or 
state legislatures unless they can be carried out without involv- 
ing the community too deeply in debt. For this reason it is a 
matter of great practical importance that the student of sani- 
tary science should make himself familiar with the relative cost 
as well as with the hygienic significance of the various methods 
of sewage removal in use. 

The different systems in use for the removal of sewage 
matters may be considered in detail under the following five 
heads : — 

1. The common privy, or privy- vault systems. 

2. The Rochdale or pail system, and its modifications. 

3. The earth- or ash- closet system. 

4. The pneumatic system of Liernur. 

5. The water-carriage systems. 

1. The Privy and Privy-well Systems. — While from a 
sanitary point of view privies of all kinds, whether wells or 
cess-pits, are to be unreservedly condemned, it is not likely that 
they will cease to be built for many years to come. It becomes 
necessary, therefore, to point out by what means the objections 
against them may be diminished, and their evil consequences in 
some measure averted. 

In the first place, a privy- vault should be perfectly water- 
tight in order to prevent pollution of the surrounding soil by 
transudation of the contained excremental matters. The walls 
should be of hard-burned brick laid in cement. The cavity 
should be small in order that the contents may be frequently re- 
moved, and not allowed to remain and putrefy for months or 
years. A water-tight hogshead sunk in the ground makes an 
economical privy-tank or receiver. A privy must not be dug in 
a cellar, or in too close proximity to the house-walls. Unless 



REMOVAL OF SEWAGE. 149 

these last precautions are taken the offensive gases from the 
mass of decomposing faecal matter in the privy will constantly 
ascend into and permeate the air of the house. 

All privies should be ventilated by a pipe passing from just 
under the privy-seat to a height of about a metre above the 
roof of the house. A gas-flame, kept burning in the upper portion 
of this pipe, will increase its ventilating power by creating a 
strong and constant upward current. 

Deodorization of the contents of privies may be secured in 
a measure by means of sulphate of iron, phenyle, carbolic acid, 
or dry earth. The first named is probably the most economical, 
most easily applied, and very effective. A solution containing 
from J to 1 kilogramme of the salt in 4 litres of water is poured 
into the privy as often as necessary to prevent offensive odors. 
This solution may be conveniently prepared by suspending a 
basket or bag containing about 25 kilogrammes of the sulphate 
in a barrel of water. In this way a saturated solution will be 
maintained until the salt has been entirely dissolved. Phenyle 
is likewise a good deodorizer as well as an excellent disinfectant. 

The most rigid deodorization by chemicals will, however, 
be less effective than thorough ventilation, for it must be re- 
membered that the mere destruction of an offensive odor is not 
equivalent to removing all the deleterious properties that may 
be present. It is not at all certain that those elements of sew- 
age which are the most offensive to the sense of smell are most 
detrimental to health. 

Privies should be emptied of their contents at stated inter- 
vals. A strict supervision should be exercised over them by the 
municipal authorities in cities and towns to prevent overflowing 
of their contents. 

In many places the method of removing the contents of 
privies is the primitive one with shovel, or dipper and bucket. 
In most cities and large towns, however, the privy- vaults or tanks 
are now emptied by means of one of the so-called odorless excavat- 
ing machines, of which there are a number of different patents. 



150 TEXT-BOOK OF HYGIENE. 

The process is rarely entirely odorless, however, as the careless- 
ness of the workmen frequently permits offensive gases to escape 
and pollute the air for a considerable distance. All the different 
forms of the apparatus act upon the pneumatic principle. One 
end of a large tube is carried into the cess-pool or vault to be 
emptied and the other attached to a pump, by means of which 
the material is pumped into a strong barrel-tank carried on 
wheels. At the top of the tank is a vent, over which is placed 
a small charcoal furnace to consume the foul gases escaping 
from the vent. 

In some cities and many of the smaller towns and villages 
in this country the primitive midden or pit system is still in use. 
A shallow pit is dug in the ground, over which is erected the 
privy. When the pit is full another is dug close by the side of 
it, and the earth from the new pit thrown upon the excrement 
in the old one. The privy is then moved over the new pit, and 
this is used until it too becomes full. The proceeding is re- 
peated as often as the pit becomes filled up with the excreta, 
until in the course of a few years all the available space in a 
yard has been honey-combed with the pits. Then the custom 
adopted in overcrowded cemeteries is followed, namely, the first 
pit is dug out again and the cycle is repeated. 

In other cities the privy- well system is largely in use. This 
is — next to the midden or shallow pit just described — the most 
pernicious system for the disposal of excreta that can be 
imagined. The wells are dug to such a depth as to reach the 
subterranean flow of water, in which the soluble excremental 
matters are constantly carried off. Hence these receptacles rarely 
fill up or need cleaning. For this reason they are popular with 
property owners ; for, next to the primitive midden, they are the 
most economical of all the various methods adopted. The utter 
perniciousness of the system is, however, plain, because the soil 
for a considerable distance around each of these wells becomes 
a mass of putrid filth, contaminating the ground-water which 
feeds the drinking-water supplies in the vicinity ; polluting also 



REMOVAL OF SEWAGE. 151 

the ground-air, which eventually reaches the surface, or the in- 
terior of houses, when the pressure of the outside atmosphere 
diminishes or the ground-water level rises. It must, therefore, 
be evident that the best ventilating arrangements, or the most 
thorough and consistent disinfection, can have very little, if any, 
effect in removing the very grave objections to this baneful 
system. 

The privy-well system for the removal of excreta cannot be 
recommended for adoption by any sanitarian. 

2. The Rochdale, or Pail-closet System. — The Eochdale 
system of removal of excreta has won the support of many dis- 
tinguished sanitarians on account of its simplicity, its economy, 
and its compliance with most sanitary requirements. The ex- 
creta, both solid and liquid, are received into a water-tight pail, 
either of wood or metal, and removed once or oftener a week, 
a clean and disinfected pail being substituted for the one 
removed. In Rochdale. Manchester, and Glasgow in Great 
Britain, in Heidelberg in Germany, and in other cities abroad, 
where this system has been introduced, it has worked satisfac- 
torily. In this country a modification of the pail system, known 
as the Eagle Sanitary Closet, has been introduced by a firm in 
Charleston, S. C. The receptacle consists of an enameled-iron 
reservoir, with a neck just large enough to fit under the seat of 
the privy, and a quantity of disinfectant solution is put into the 
receptacle to prevent putrefaction of the excreta. The recep- 
tacles are replaced by clean ones every week. 

Mr. James T. Gardner, Director of the New York State 
Sanitary Survey, says, in a special report on methods of sewerage 
applicable in small towns and villages, concerning the pail 
system 1 : — 

"Eochdale is a city of some 70,000, and Manchester of 
between 400,000 and 500,000 inhabitants. The higher class 
of houses are allowed to have water-closets, but four-fifths of 
the people are obliged to have ' pail-closets ' in their yards built 

1 Second Annual Report of New York State Board of Health, pp. 322, 323. 



152 TEXT-BOOK OF HYGIENE. 

according to plans of the Health Department. Their essential 
features are : A flag-stone floor, raised a few inches above the 
level of the yard ; a hinged seat, with a metal rim underneath 
for directing urine into the pail, which stands on the flag directly 
beneath the seat; a hinged front and back to the seat, so that 
the pail or tub may be easily taken out and the place cleaned ; 
and a 6-inch ventilating pipe from under the seat to above the 
roof. In Rochdale they use a wooden pail or tub made of half 
of a disused parafflne cask, holding about 40 kilogrammes ; in 
Manchester the ' pail ' is of galvanized iron and holds 40 litres. 
Under the direction of the authorities, they are removed once a 
week in covered vans, which bring clean tubs to be put in the 
place of the full ones taken away. Each tub is covered with a 
close-fitting double lid before removal. The tubs are taken to a 
depot, where their contents are deodorized and prepared as 
manure by mixing with ashes and a small proportion of gypsum 
to fix the ammonia. Subsequently, street-sweepings and the 
refuse of slaughter-houses are added. At Manchester there is 
by the side of each closet a very simple ash-sifter, from which 
the ashes fall into the tub and help to deodorize its contents. 

" The manure at Rochdale sells for about four-fifths of the 
cost of the collection and preparation. 

" In 1873 the net cost to the town of removing and dispos- 
ing of the house dry refuse and excrement was only about $95 
per annum per 1000 of population, — less than 10 cents a person 
per annum. 

" The system has been in operation more than twelve years. 

u The tubs are removed in the day-time without offensive 
odor. 

" Where ashes are frequently thrown into the tubs at Man- 
chester, very little odor is to be perceived in the closets. 

" For the villages of the State, which can have no general 
water-supply, I would unhesitatingly advise the use of the 
' pail ' or tub system as practiced in Manchester, England, as 
being, from a sanitary point of view, an immense improvement 



REMOVAL OF SEWAGE. 153 

over the death-breeding privy-vaults in common use. The 
cheapness of the plan and the small ness of the original outlay 
of brains and money, in comparison with that needed to build 
a good sewer system, will make it possible to introduce a tub- 
privy system into most villages half a century before sewers 
would meet with any consideration. 

" At a small cost the existing privy- vaults can be cleaned 
and filled, and the privies altered into healthful tub-closets. The 
town authorities must then arrange for the removal of the tubs 
once a week, and for their thorough cleansing and disinfecting. 
Any isolated house, or group of houses, can use the tub system, 
taking care of it themselves. If the plan is adopted in villages 
it will doubtless spread into the country, and become the most 
powerful means of abolishing the fatal privy-vaults which are 
poisoning the farm-wells." 

3. Earth- and Ash- Closets. — The earth- and ash- closets 
are devices in use to a large extent in England, and to a less 
degree in this country, for the purpose of rendering human ex- 
creta inodorous by covering them immediately after they are 
voided with dry earth or ashes. The earth-closet is the inven- 
tion of the Rev. Henry Moule, of England, and consists of an 
ordinary commode or closet, the essential feature of which is a 
reservoir containing dried earth or ashes, a quantity of which, 
amounting to about twice the quantity of faeces voided, is thrown 
upon the evacuation either by hand or by means of an auto- 
matic apparatus called a "chucker." Just as in the ordinary 
water-closet, by raising a handle a supply of water is thrown 
into the hopper to wash down the faeces into the soil-pipe, so, in 
the usual form of the earth-closet, raising the handle projects a 
quantity of earth upon the evacuated faeces and urine. By this 
means the excreta are rendered entirely inodorous and dry. 
The contents of the closets may be collected into a heap in a 
dry place. In the course of a few months the organic constit- 
uents have become oxidized, and the earth may be used over 
again for a number of times. A well-known sanitarian states 



154 



TEXT-BOOK OF HYGIENE. 



that he lias used sifted anthracite coal-ashes ten or twelve times 
over in the course of three years. During this time the material 
under no circumstances gave any indication that it was " any- 
thing but ashes, with a slight admixture of garden soil." 1 

Dr. Buchanan, of England, comparing the advantages of 
the earth-closet with those of the water-closet, says : "It is 
cheaper in original cost ; it requires less repairs ; it is not in- 
jured by frost ; it is not damaged by improper substances being 





Fig. 4. — Pull - up Handle Commode, 
showing the door open for remov- 
ING Pail. The Flap of the Seat 
and Earth-Reservoir are also Par- 
tially Raised to show the Con- 
struction. 



Fig. 5.— Showing the Apparatus 
Mounted on Bearers as when 
Fixed. Seat Removed, showing Me- 
chanical Arrangement. 



thrown down it ; and it very greatly reduces the quantity of 
water required by each household." 2 

In cities and towns the removal of the excreta should be 
carried out by or under the immediate direction of the mu- 
nicipal sanitary authorities. If this is neglected, abuses are 
liable to creep in which will vitiate the performance of any 
system, however faultless, when properly managed. 

Many advocates of the pail, dry earth, or privy systems urge 
the advantage of the large quantity of valuable manure which 



1 The Sanitary Drainage of Houses and Towns, Waring, p. 250. 2d ed., 1881. 
8 Quoted in Waring, above cited, p. 264. 



REMOVAL OF SEWAGE. 155 

can be realized by converting the excremental matters into pou- 
drette and other fertilizing compounds. Experience has shown, 
however, that the cost of preparing a satisfactory fertilizer from 
human excrement is much greater than can be realized from its 
sale. In all places in Great Britain and the continent of Europe 
where it has been tried the decision is against its practicability. 
The agricultural consideration should, however, be a secondary 
one, if the systems mentioned are economical and meet the 
sanitary requirements (which the privy system certainly does 
not). The adoption of one or other of them may be secured 
where more perfect but more complicated and expensive systems 
may be out of the question. 

4. The Pneumatic System of Liernur. — A system which 
seems to be useful in larger cities, especially where the topo- 
graphical conditions are such as to render necessary mechanical 
aid in overcoming obstacles to natural drainage, is the pneu- 
matic system devised by Captain Liernur, of Holland, and 
generally known as the Liernur system. It consists of a set of 
soil-pipes running from the water-closets to central district 
reservoirs, from which the air is exhausted at stated intervals. 
When a vacuum is created in the reservoir the contents of the 
water-closets and soil-pipes are driven forcibly into the reservoir 
by the pressure of air. The district reservoirs are connected by 
a separate system of pipes with a main depot, and the transfer 
of the faecal matter from the former to the latter is also accom- 
plished with the aid of pneumatic pressure. The complete 
system of Liernur provides that at the main depot the faecal 
matter shall be treated with chemicals, evaporated, and con- 
verted into a dry fertilizer — poudrette. It appears from the 
published reports that while the system has been partially 
adopted in three Dutch cities, in only one of them, Dortrecht, 
has the machinery for manufacturing poudrette been established. 
With reference to this Erismann 1 says: "It seems never to have 

1 Von Pettenkofer und Ziemssen : Handbuch der Hygiene. U Th., II Abth., 1 Hefte, 
p. 140. 



156 TEXT-BOOK OF HYGIENE. 

been ill regular working order, for the faecal masses are mixed 
with street-sweepings and ashes into a compost-mass, which 
causes no little discomfort in the neighborhood by the offensive 
odors. In Amsterdam the faecal matters, which frequently do 
not find a ready sale, are partly made into a compost with 
sweepings, partly used to fertilize meadows, or simply discharged 
into the water." 

As to the practical working of the system the opinions 
differ widely. While the majority of sanitarians, including 
Virchow, von Pettenkofer, and Mr. Rawlinson, object to it as 
not fulfilling the demands of hygiene, the system has also been 
criticized by engineers as not being in accordance with the well- 
known principles of their science. 1 

Two other plans for the removal of faecal matter by pneu- 
matic pressure have been invented, namely, the Shone and the 
Berber systems. Neither of these has been adopted to any 
considerable extent. Both seem to the author to fall far short 
even of the merits of the Liernur system. 

5. The Water- Carriage System of Sewerage. — Two sys- 
tems of removal of sewage by water-carriage are in use at the 
present time. They are technically known as the " combined " 
and the "separate" systems. In the former, which is the sys- 
tem upon which the most of the sewers in this country are 
constructed, all excreta, kitchen-slops, waste-water from baths 
and manufacturing establishments, as well as storm-water, are 
carried off in the same conduits. In the separate system, on 
the other hand, the removal of the storm-water is provided for, 
either by surface or under-ground drains, not connected with the 
sewers proper, in which only the discharge from water-closets 
and the refuse-water from houses and factories are conveyed. 
In the separate system the pipes are of such small calibre that 
a constant flow of their contents is maintained, preventing 

1 Papers by Maj. C. H. Latrobe and Col. Geo. E. Waring, Jr., in Fifth Biennial Report 
Md. State Board of Health. Sec also, in favor of system, a paper by Dr. C. W. Chancellor, in 
same publication, and an elaborate description by the same author in Trans. Med. and Chir. 
Faculty of Md., 1883. 



REMOVAL OF SEWAGE. 157 

deposition of suspended matters and diminishing decomposition 
and the formation of sewer-gas. 

In the combined system, on the other hand, the sewers 
must be made large enough to receive the maximum rain-fall of 
the district. This requires a calibre greatly in excess of the 
ordinary needs of the sewer, and furnishes favorable conditions 
for the formation of sewer-gas and the development of minute 
vegetable organisms. The ordinary flow in a sewer of large 
calibre is usually so sluggish as to promote the deposition of 
solid matters and the gradual obstruction of the sewer. 

It is the opinion of the most advanced sanitarians that the 
separate system fulfills the demands of a rational system of 
sewerage better than any other at present in use. The objec- 
tions to the combined system are so many and so great that it 
does not seem advisable for sanitary authorities to recommend 
the construction of sewers on this principle in the future. 

The separate system of sewerage, indorsed as it is by high 
engineering and sanitary authorities, and by a satisfactory, prac- 
tical test of twelve years in the city of Memphis and of nine years 
in the town of Keene, N. H., seems to the author to possess 
merits above any other plan for the removal of excreta and 
house- wastes. The following description is from a paper by 
Col. George E. Waring, Jr. : " A perfect system of sanitary 
sewerage would be something like the following: No sewer 
should be used of a smaller diameter than 6 inches (15 centi- 
metres): a, because it will not be safe to adopt a smaller size 
than 4-inch (10 centimetres) for house-drains, and the sewer 
must be large enough to surely remove whatever may be de- 
livered by these; 6, because a smaller pipe than 6-inch would 
be less readily ventilated than is desirable ; c, and because it is 
not necessary to adopt a smaller radius than 3 inches (5 centi- 
metres) to secure a cleansing of the channel by reasonably 
copious flushing. 

"No sewer should be more than 6 inches (15 centimetres) 
in diameter, until it and its branches have accumulated a 



158 TEXT-BOOK OF HYGIENE. 

sufficient flow at the hour of greatest use to fill this size half full, 
because the use of a larger size would be wasteful, and because 
when a sufficient ventilating capacity is secured, as it is in the 
use of a 6-inch pipe, the ventilation becomes less complete as 
the size increases, leaving a larger volume of contained air to 
be moved by the friction of the current, or by extraneous in- 
fluences, or to be acted upon by changes of temperature and 
of volume of flow within the sewer. 

"The size should be increased gradually, and only so 
rapidly as is made necessary by the filling of the sewer half 
full at the hour of greatest flow. 

" Every point of the sewer should, by the use of gaskets 
or otherwise, be protected against the least intrusion of cement, 
which, in spite of the greatest care, creates a roughness that is 
liable to accumulate obstructions. 

" The upper end of each branch sewer should be provided 
with a Field's flush-tank of sufficient capacity to secure the 
thorough daily cleansing of so much of the conduit as from its 
limited flow is liable to deposit solid matters by the way. 

" There should be sufficient man-holes, covered by open 
gratings, to admit air for ventilation. If the directions already 
given are adhered to, man-holes will not be necessary for cleans- 
ing. The use of the flush-tank will be a safeguard against 
deposit. With the system of ventilation about to be described, 
it will suffice to place the man-holes at intervals of not less than 
1000 feet (305 metres). 

" For the complete ventilation of the sewers it should be made 
compulsory for every householder to make his connection without 
a trap, and to continue his soil-pipe above the roof of his house. 
That is, every house connection should furnish an uninter- 
rupted ventilation-channel 4 inches (10 centimetres) in diameter 
throughout its entire length. This is directly the reverse of the 
system of connection that should be adopted in the case of 
storm-water and street-wash sewers. These are foul, and the 
volume of their contained air is too great to be thoroughly ven- 



REMOVAL OF SEWAGE. 159 

tilated by such appliances. Their atmosphere contains too much 
of the impure gases to make it prudent to discharge it through 
house-drains and soil-pipes. With the system of small pipes 
now described, the flushing would be so constant and complete 
and the amount of ventilation furnished, as compared to volume 
of air to be changed, would be so great, that what is popularly 
known as ' sewer-gas ' w T ould never exist in any part of the 
public drains. Even the gases produced in the traps and pipes 
of the house itself would be amply rectified, diluted, and removed 
by the constant movement of air through the latter. 

"All house connections with the sewers should be through 
inlets entering in the direction of the flow, and these inlets 
should be funnel-shaped so that their flow may be delivered at 
the bottom of the sewer, and so that they may withdraw the air 
from its crown; that is, the vertical diameter of the inlet at its 
point of junction should be the same as the diameter of the 
sewer. 

"All changes of direction should be on gradual curves, and, 
as a matter of course, the fall from the head of each branch to 
the outlet should be continuous. Reduction of grade within 
this limit, if considerable, should always be gradual. 

"So far as circumstances will allow, the drains should be 
brought together, and they should finally discharge through one 
or a few main outlets. 

" The outlet, if water-locked, should have ample means for 
the admission of fresh air. If open, the mouth should be pro- 
tected against the direct action of the wind. 

"It will be seen that the system of sewerage here described 
is radically different from the usual practice. It is cleaner, is 
much more completely ventilated, and is more exactly suited to 
the work to be performed. It obviates the filthy accumulation 
of street-manure in catch-basins and sewers, and it discharges all 
that is delivered to it at the point of ultimate outlet outside the 
town before decomposition can even begin. If the discharge is 
of domestic sewage only, its solid matter will be consumed by 



160 TEXT-BOOK OF HYGIENE. 

fishes if it is delivered into a water-course, and its dissolved 
material will be taken up by aquatic vegetation. 

"The limited quantity and the uniform volume of the 
sewage, together with the absence of dilution by rain-fall, will 
make its disposal by agricultural or chemical processes easy and 
reliable. 

"The cost of construction, as compared with that of the 
most restricted storm-water sewers, will be so small as to bring 
the improvement within the reach of the smaller communities. 

"In other words, while the system is the best for large 
cities, it is the only one that can be afforded in the case of 
small towns. 

" Circumstances are occasionally such as to require extensive 
engineering works for the removal of storm- water through very 
deep channels. Ordinarily, the removal of storm- water is a very 
simple matter, if we will accept the fact that it is best carried, 
so far as possible, by surface gutters, or, in certain cases, by 
special conduits, placed near the surface. 

" It is often necessary, in addition to the removal of house- 
waste, to provide for the drainage of the subsoil. This should 
not be effected by open joints in the sewers; because the same 
opening that admits soil-water may, in dry seasons and porous 
soils, permit the escape of sewage matters into the ground, 
which is always objectionable. 

" Soil- water drains may be laid in the same trench with the 
sewers, but preferably, unless they have an independent outlet, 
on a shelf at a higher level. When they discharge into the 
sewer they should always deliver into its upper part, or into a 
man-hole at a point above the flow-line of the sewage." 1 

The establishment of a system of sewerage presupposes a 
constant and abundant supply of water to keep all closets clean 
and all house-drains and street-sewers well flushed. Where this 
cannot be obtained, sewers would be likely to prove greater 
evils than benefits. In such cases one of the methods of removal 

1 The Sewering and Drainage of Cities, Waring, Public Health, vol. v, p. 35. 



REMOVAL OF SEWAGE. 161 

of excreta before mentioned, either the pail- or earth- closet 
system, should be adopted. 

The final disposal of sewage is a problem that depends for 
its solution partly upon the agricultural needs of the country 
around the city to be sewered, partly upon the proximity of 
large bodies of water or running streams. When the city is 
situated upon or near large and swiftly-flowing streams, the 
sewage may be emptied directly into the stream without seriously 
impairing the purity of the latter, although the principle of thus 
disposing of sewage is wrong. Dilution, deposition, and oxida- 
tion will soon remove all appreciable traces of the sewage of 
even the largest cities. Where, on the other hand, the stream 
is inadequate in size to carry off the sewage, or where, as in the 
Seine and Thames, the current is sluggish, some other method 
of final disposal must be adopted. 

In many cities of Great Britain and the continent of Europe 
the disposal of the sewage by irrigation of cultivated land has 
been practiced for a number of years. The reports upon the 
working of the system are generally favorable, although some 
sanitarians express doubts of the efficiency of the system. In 
using sewage for the irrigation of land, two objects are secured : 
first, the fertilization of the land by the manurial constituents 
of the sewage, and, second, the purification of the liquid portion 
by filtration through the soil. The organic matters which have 
been held back by the soil undergo rapid oxidation in the presence 
of air and the bacteria of decay, and are converted into plant- 
food, or into harmless compounds. Sewage irrigation, as prac- 
ticed in Europe, must make provision for the disposal of a very 
large proportion of water in the sewage (street- wash, storm- 
water), which requires much larger areas of land than would be 
needed if only sewage material proper (water-closet and kitchen- 
waste) was to be thus disposed of. In this country a practical 
experiment has recently been made at Pullman, Illinois, delivering 
only the sewage materials above mentioned upon the irrigation 
area. The success of the experiment is said to be satisfactory. 



1(32 TEXT-BOOK OF HYGIENE. 

All land used for sewage irrigation should be drained with 
drain- tile at a depth of 3 to 6 feet (1 to 2 metres) below the 
surface, in order to promote a rapid carrying off of the watery 
portion of the sewage, purified by filtration through the soil. A 
sandy loam is the best soil for irrigation. Clay is not sufficiently 
permeable to air and water, while pure sand allows the sewage 
to pass through too readily, before the organic matters in it 
have been sufficiently oxidized. It has been shown that the 
roots of plants assist largely in the oxidation of organic matter. 

The entire process of collecting and finally disposing of 
sewage matters, from the moment they are received in the house- 
receptacles until discharged into the swiftly-flowing stream or on 
the sewage farm, should be void of offense to the senses of sight 
or smell. With a proper construction and management of 
sewerage works, on the lines indicated in this chapter, it is 
believed these results can be attained. 

During the past five or six years a number of experi- 
ments have been made in this country with various processes for 
the disposal of excreta and garbage by cremation. In a general 
way the principle may be pronounced a success, although its 
proper application in practice is still under discussion. 

[The following works give fuller details upon the matters 
treated in the two foregoing chapters: — 

Erismann, Entfernung der Abfallstoffe. Hdbcli. d. Hygiene, etc., 
II Tli., I Abth., 1 Hlfte.— C. F. Folsom, Seventh Report Mass. State 
Board of Health, 1876, p. 276. — Soyka, Stadte-reinigung, in Realency- 
clopaedie d. ges. Heilk.,Bd. xiii, p. 14 et seq. — Pettenkofer, The Sanitary 
Relations of the Soil, in Pop. Sci. Monthly, vol. xx, pp. 332, 468. — Cor- 
field and Parkes, The Treatment and Utilization of Sewage, 1887. — Re- 
ports of the Committee on Destruction of Garbage and Refuse, Public 
Health, vols, xiv and xv. — Soyka, Der Boden in Hdbch. d. Hygiene, 
I Thl., 2 Abth., 3 Heft.— W. Santo Crimp, Sewage-Disposal Works.— 
Waring, Modern Methods of Sewage Disposal.] 



QUESTIONS TO CHAPTER V. 

Removal of Sewage. 

Why must arrangements be made in all large communities for the 
removal of sewage ? To what do the organic constituents of sewage 
give rise, and what is the effect upon health of the continued inhalation 
of these products ? How else may the impregnation of the soil with 
sewage endanger health ? What, then, is the object of any s) r stem of 
sewage removal ? What will likely govern the choice and adoption of a 
sewage-removal system by any community ? 

What different systems are in use at the present time? Which of 
these is the worst and most unsanitary ? In case the privy system is to 
be considered, what conditions should be insisted upon ? How may a 
privy be ventilated? Wiry should a privy not be located in a cellar nor 
too near the house? What substances may be used to deodorize the 
contents of privy-vaults, and how ? Are deodorizers always disinfect- 
ants, and is the danger necessarily removed when the odor is destroyed? 
How often should privy-vaults be emptied? How may this be done 
without offense to the senses ? What are the grave objections to the 
midden or shallow-pit s} r stem, and to digging the vault or cess-pool to 
the level of the ground-water ? 

What is meant by the Rochdale or pail-closet system ? What are 
some of its advantages ? What can be said of its efficacy for large com- 
munities and for the economy of administration ? What is an earth- 
closet, and upon what does its efficacy depend ? What are some of its 
advantages ? 

Describe the pneumatic system of Liernur. Has it apparently been 
satisfactory in its workings ? What other systems have employed the 
pneumatic principle, and with what success ? 

What do we mean by the water-carriage system of sewerage ? What 
two systems are embraced under this head ? What is the distinction 
between the two ? Which is in most common use ? What must be the 
size of the sewers in the combined sj^stem, and what are the consequent 
objections ? Why does the separate system seem the better ? Describe 
the latter in detail. What governs the size of the drains in the separate 
system ? How is this system kept clean and free from obstructions ? 
How is it to be ventilated ? How does it differ in this respect from the 
combined S3^stem ? What are some of the especial points to be observed 

(163) 



164 QUESTIONS TO CHAPTER V. 

in the construction ? What may be said as to cost of construction and 
as to the ultimate disposal of the sewage? Why should sewers not be 
emplo} r ed to drain the subsoil? How may this be done? 

What does the establishment of a sewerage system presuppose ? If 
plenty of water cannot be had, what sj^stem of sewage removal should 
be adopted ? 

In what way may we finally dispose of the sewage ? What are the 
objections to discharging it into running streams ? How will it be finally 
disposed of in such a stream? What is meant by the irrigation, the 
sub-irrigation, and the filtration methods ? What becomes of the organic 
matter of the sewage in each case? What of the sewage water ? What 
sort of soil is needed for the irrigation method ? What can be said of 
the disposal of sewage and garbage by cremation ? 



CHAPTER VI. 

Construction of Habitations. 



The importance of observing the principles of hygiene in 
the construction of habitations for human beings is not suffi- 
ciently appreciated by the public. Architects and builders them- 
selves have not kept pace with the sanitarian hi the study of the 
conditions necessary to be observed in building a dwelling-house 
which shall answer the requirements of sanitary science. 

In an investigation conducted by Dr. Villerme 1 it was found 
that in France, from 1821 to 1827, of the inhabitants of arron- 
dissements containing 7 per cent, of badly-constructed dwellings, 
1 person out of every 72 died ; of inhabitants of arrondissements 
containing 22 per cent, of badly-constructed dwellings, 1 out of 
65 died ; while of the inhabitants of arrondissements containing 
38 per cent, of badly-constructed dwellings, 1 out of every 45 died. 

Inseparable from the question of the defective construction 
of dwellings is that of overcrowding in cities, because the most 
crowded portions of a city are at the same time those in which 
the construction of dwellings is most defective from a hygienic 
stand-point. The following tables show the relations of the 
death-rate to density of population in various large cities of 
Europe, and also the relations between overcrowding in dwell- 
ings and the mortality from contagious diseases : — 

Table XVII. 

RELATION OF DEATH-RATE TO DENSITY OF POPULATION. 



City. 


Mean Number of Inhab- 
itants to each House. 


Average Death-rate per 
1000 Inhabitants. 


London 

Berlin 

Paris 

St. Petersburg 

Vienna 


8 
32 
35 
52 

55 


24 
25 

28 
41 
47 



1 Quoted in Realencyclopaedia d. ges. Heilk, Bd. ii, 71. 



(165) 



166 TEXT-BOOK OF HYGIENE. 

In Glasgow, the death-rate in apartments with 1.31 occu- 
pants is 21.7 per 1000, while in apartments with 2.05 occupants 
the rate is 28.6 per 1000. 

In Buda-Pesth, in 1872-73, it was found that out of every 100 
deaths from all causes there were, from contagious diseases : — 

20 deaths in dwellings with 1 to 2 persons in each room. 

oq u u u u 3 a 5 a u a u 

32 u u a a g u |Q u a u a 

19 " " " " over 10 " « " " 

Dr. Jose A. de los Kios gives the following statistics, bear- 
ing upon the mortality of cholera, in relation to the number of 
persons occupying one room when attacked by it : — 

Of 10,000 persons attacked by cholera, and living 1 person 
to the .room, 68 died. 

Of 10,000 persons attacked by cholera, from 1 to 2 to the 
room, 131 died. 

Of 10,000 persons attacked by cholera, living 2 to 4 to the 
room, 219 died. 

Of 10,000 persons attacked by cholera, living 4 or more to 
the room, 327 died. 

These figures show very clearly the vital importance of the 
application of sanitary laws in the construction and occupation 
of dwellings. 

Another curious and suggestive point is presented by some 
statistical researches on the mortality of Berlin, in regard to the 
death-rate among persons living in different stories of houses. It 
was found, for example, that the mortality in fourth-story dwell- 
ings is higher than in the lower stories. Even basement dwell- 
ings furnish a lower death-rate. Still-births, especially, occur 
in a larger proportion among the occupants of the upper stories 
of houses. This may be explained by the unfavorable effects of 
frequent stair-climbing, especially in pregnant women. 

It is in the death-rate among young children that the effects 
of overcrowding and unsanitary construction of dwellings are 
especially manifest. The mortality returns from all the large 



CONSTRUCTION OF HABITATIONS. 



167 



cities of the world give mournful evidences of this every 
summer. 

The researches of Dr. H. I. Bowditch upon soil-wetness, to 
which reference has already been made in a previous chapter, 
show conclusively that persons living in houses situated upon 
or near land habitually or excessively wet, are especially prone 
to be attacked by pulmonary consumption. Dr. Buchanan 1 has 
corroborated the truth of Dr. Bowditch's observations by show- 
ing, from the records of a number of cities and towns of Great 
Britain, that, with the introduction of a good drainage system, 
bringing about a depression and uniformity of level of the 
ground-water, the mortality from consumption and other dis- 
eases very markedly diminished. The following table, showing 
the proportionate amount of this diminution, is abridged from 

the official reports 2 : — 

Table XVIII. 

RESULTS OP SANITARY WORK. 



Name of Place. 



Banbury . 

Cardiff . . 

Croydon . 

Dover . . 

Ely . . . 

Leicester . 
Macclesfield 
Merthyr 

Newport . 

Rugby . . 

Salisbury . 

Warwick . 



Population 
m 1861. 


Average 
Mortality per 

1000 before 
Construction 

of Works. 


Average 
Mortality 

per 1000 
since Com- 
pletion of 
Works. 


Saving of 

Life 
(percent.). 


Reduc- 
tion of 

Typhoid 
Fever 

Rate (per 
cent.) . 


10,238 


23.4 


20.5 


12A 


48 


32,954 


33.2 


22.6 


32 


40 


30,229 


23.7 


18.6 


22 


63 


23,108 


22.6 


20.9 


7 


36 


7,847 


23.9 


20.5 


14 


56 


68,056 


26.4 


25.2 


H 


48 


27,475 


29.8 


23.7 


20 


48 


52,778 


33.2 


26 2 


18 


60 


24,756 


31.8 


21.6 


32 


36 


7,818 


19.1 


18.6 


H 


10 


9,030 


27.5 


21.9 


20 


75 


10,570 


22.7 


21.0 


n 


52 



Reduc- 
tion in 
Rate of 
Phthisis 
(percent.). 



41 
17 
17 
20 
47 
32 
31 
11 
32 
43 
49 
19 



The following points must be taken into account in building 
a house in accordance with sanitary principles : — 

I. — SITE. 

The building-site should be protected against violent 
winds, although a free circulation of air all around the house 

1 Ninth and Tenth Reports of the medical officer to the Privy Council. 

2 Sanitary Engineering, Baldwin Latham, p. 2. Chicago, 1877. 



168 TEXT-BOOK OF HYGIENE. 

must be secured. Close proximity to cemeteries, marshes, and 
injurious manufacturing establishments or industries must be 
avoided if possible. A requisite of the highest importance is 
the ability to command an abundant supply of pure water for 
drinking and other purposes. A neglect of this precaution will 
be sure to result to the serious inconvenience, if not detriment, 
of the occupants of the house. 

II. CHARACTER OF THE SOIL. 

The soil should be porous and free from decomposing ani- 
mal or vegetable remains, or excreta of man or animals. It 
should be freely permeable to air and water, and the highest 
level of the ground- water should never approach nearer than 
3 metres to the surface. The fluctuations of the ground-water 
level should be limited. In this connection, attention is again 
called to the aphorism of Dr. DeChaumont. 1 

It is impossible to say positively that any kind of soil is 
either healthy or unhealthy, merely from a knowledge of its 
geological characters. The accidental modifying conditions 
above referred to, viz., organic impurities, moisture, the level 
and fluctuations of the ground-water, are of much greater 
importance than mere geological formation. The late Dr. 
Parkes, however, regarded the geological structure and conforma- 
tion as of no little importance, and summarized the sanitary 
relations of soils, variously constituted, as follows 2 : — 

"1. The Granitic, Metamorphic, and Trap Eoc7cs. — Sites 
on these formations are usually healthy ; the slope is great, water 
runs off readily; the air is comparatively dry; vegetation is not 
excessive; marshes and malaria are comparatively infrequent; 
and few impurities pass into the drinking-water. 

" When these rocks have been weathered and disintegrated 
they are supposed to be unhealthy. Such soil is absorbent of 
water; and the disintegrated granite of Hong Kong is said to 

* Chapter iv, p. 130. 

' Practical Hygiene, 6th ed., vol. i, p. 359, 



CHARACTER OF THE SOIL. 169 

be rapidly permeated by a fungus; but evidence as to the effect 
of disintegrated granite or trap is really wanting. 

"In Brazil the syenite becomes coated with a dark sub- 
stance and looks like plumbago, and the Indians believe this 
gives rise to 'calentura,' or fevers. The dark granitoid, or 
metamorphic trap, or hornblendic rocks in Mysore, are also said 
to cause periodic fevers ; and iron hornblende, especially, was 
affirmed by Dr. Heyne, of Madras, to be dangerous in this 
respect. But the observations of Bichter on similar rocks in 
Saxony, and the fact that stations on the lower spurs of the 
Himalayas on such rocks are quite healthy, negative Heyne's 
opinion. 

"2. The Clay Slate.— These rocks precisely resemble the 
granite and granitoid formations in their effect on health. They 
have usually much slope, are very impermeable, vegetation is 
scanty, and nothing is added to air or drinking-water. 

"They are consequently healthy. Water, however, is 
often scarce, and as to the granite districts, there are swollen 
brooks during rain, and dry water-courses at other times swelling 
rapidly after rains. 

"3. The Limestone and Magnesian Limestone Rocks. — 
These so far resemble the former that there is a good deal of 
slope and rapid passing off of water. Marshes, however, are 
more common, and may exist at great heights. In that case, 
the marsh is probably fed with water from some of the large 
cavities which in the course of ages become hollowed out in the 
limestone rocks by the carbonic acid in the rain, and form 
reservoirs of water. 

"The drinking-water is hard, sparkling, and clear. Of 
the various kinds of limestone, the hard oolite is best and 
magnesian is worst; and it is desirable not to put stations on 
magnesian limestone if it can be avoided. 

"4. The Chalk. — The chalk, when mixed with clay, and 
permeable, forms a very healthy soil. The air is pure, and 
the water, though charged with calcium carbonate, is clear, 



170 TEXT-BOOK OF HYGIENE. 

sparkling, and pleasant. Goitre is not nearly so common, nor 
apparently calculus, as in the limestone districts. 

"If the chalk be marly, it becomes impermeable, and is 
then often damp and cold. The lower parts of the chalk, which 
are underlaid by gault clay, and which also receive the drainage 
of the parts above, are often very malarious; and in America 
some of the most marshy districts are in the chalk. 

" 5. The Sandstones. — The permeable sandstones are very 
healthy ; both soil and air are dry ; the drinking-water is, how- 
ever, sometimes impure. If the sand be mixed with much clay, 
or if clay underlies a shallow sand-rock, the site is sometimes 
damp. 

" The hard millstone-grit formations are very healthy, and 
their conditions resemble those of granite. 

" 6. Gravels of any depth are always healthy, except when 
they are much below the general surface, and water rises through 
them. Gravel hillocks are the healthiest of all sites, and the 
water, which often flows out in springs near the base, being 
held up by the underlying clay, is very pure. 

" 7. Sands. — There are both healthy and unhealthy sands. 
The healthy are the pure sands, which contain no organic 
matter, and are of considerable depth. The air is pure, and so 
is often the drinking-water. Sometimes the drinking-water con- 
tains enough iron to become hard, and even chalybeate. The 
unhealthy sands are those which, like the subsoil of the Landes, 
in southwest France, are composed of silicious particles (and 
some iron) held together by a vegetable sediment. 

"In other cases sand is unhealthy from underlying clay or 
laterite near the surface, or from being so placed that water 
rises through its permeable soil from higher levels. Water may 
then be found within 3 or 4 feet of the surface ; and in this c^se 
the sand is unhealthy and often malarious. Impurities are 
retained in it and effluvia traverse it. 

"In a third class of cases the sands are unhealthy because 
they contain soluble mineral matter. Many sands (as, for ex- 



CHARACTER OF THE SOIL. 171 

ample, in the Punjab) contain magnesium carbonate and lime- 
salts, as well as salts of the alkalies. The drinking-water may 
thus contain large quantities of sodium chloride, sodium carbon- 
ate, and even lime and magnesian salts and iron. Without 
examination of the water it is impossible to detect these points. 

u 8. Clay, Dense Marls, and Alluvial Soils Generally. — 
These are always regarded with suspicion. Water neither runs 
off nor runs through ; the air is moist ; marshes are common ; 
the composition of the water varies, but it is often impure with 
lime and soda salts. In alluvial soils there are often alterations 
of thin strata of sand, and sandy, impermeable clay. Much 
vegetable matter is often mixed with this, and air and water are 
both impure. 

" The deltas of great rivers present these alluvial characters 
in the highest degree, and should not be chosen for sites. If 
they must be taken, only the most thorough drainage can make 
them healthy. It is astonishing, however, what good can be 
effected by the drainage of even a small area, quite insufficient 
to affect the general atmosphere of the place ; this shows that it 
is the local dampness and the effluvia which are the most 
hurtful. 

"9. Cultivated Soils. — Well-cultivated soils are often 
healthy ; nor at present has it been proved that the use of manure 
is hurtful. Irrigated lands, and especially rice-fields, which not 
only give a great surface for evaporation, but also send up 
organic matter into the air, are hurtful. In Northern Italy, 
where there is a very perfect system of irrigation, the rice- 
grounds are ordered to be kept 14 kilometres (8.7 miles) from 
the chief cities, 9 kilometres (5.6 miles) from the lesser cities and 
the forts, and 1 kilometre (1094 yards) from the smaller towns. 
In the rice countries of India [and America] this point should 
not be overlooked." 

Where a wet, impermeable, or impure soil must, of neces- 
sity, be chosen as a building- site, it should be thoroughly 
drained. The minimum depth at which drains are laid should 



172 TEXT-BOOK OF HYGIENE. 

be not less than 1 J metres below the floor of the cellar or base- 
ment. Such a soil should be covered with a thick, impervious 
layer of asphaltum or similar cement under the house, in order 
to prevent the aspiration of the polluted ground-air into the 
building. 

It is a frequent custom in cities to fill in irregularities of 
the building-site with street-sweepings and garbage, which 
always contain large quantities of decomposing organic matters. 
This is a gross violation of the plainest principles of hygiene. 
It is almost equally reprehensible to use such decaying or 
putrefying organic material for the purpose of grading streets 
or sidewalks in cities and towns. 1 It should be the constant 
endeavor of all sanitary authorities to prevent pollution of the 
soil as much as possible in villages, towns, and cities. 

Where houses are built on the declivity of a hill, the upper 
wall should not be built directly against the ground, as it would 
tend to keep the wall damp. A vacant space should be left 
between the wall and the ground to permit free access of air 
and light. 

In addition to, or in default of, drainage, the drying of soil 
can be promoted by rapidly-growing plants, which absorb water 
from the soil and give it out to the air. The sunflower and the 
eucalyptus tree are the most available for this purpose. 

III. — THE MATERIAL OF WHICH THE HOUSE IS BUILT. 

The nature of the most appropriate building material de- 
pends upon so many collateral circumstances that definite rules 
cannot be laid down. As a general rule, moderately hard 
burned brick is the most serviceable and available material. It 
is easily permeable by the air, and so permits natural ventila- 
tion through the walls, unless this is prevented by other means. 

1 During the very fatal epidemic of yellow fever in New Orleans, in 1878, it was ascer- 
tained that a contractor for street-work used the garbage and street-scrapings to grade the bed 
of the streets. Even though in this case it may not have intensified the epidemic in these 
localities, the practice is so contrary to the simplest sanitary laws that it should nowhere be 
tolerated. The author is aware, however, that the "made-ground" of nearly every city in this 
country is composed largely of just such material. All sanitarians should protest against a 
continuance of this pernicious practice. 



MATERIAL OF WHICH THE HOUSE IS BUILT. 173 

It does not absorb and hold water readily ; hence, damp walls 
are infrequent if brick is used. It is probably, of all building 
material, the most durable. On account of its porosity a brick 
wall is a poor conductor of heat. It therefore prevents the 
rapid cooling of a room in cold weather, and likewise retards 
the heating of the inside air from without in summer. Another 
very great advantage is its resistance to a very high degree of 
heat, brick being probably more nearly fire-proof than any 
other building material. 

In hot climates light wooden buildings are advantageous, 
because they cool off very rapidly after the sun has disappeared. 
On account of the numerous joints and fissures in a frame 
building, natural ventilation goes on very readily and to a con- 
siderable extent. 

Next to brick, granite, marble, and sandstone are the most 
serviceable building materials. Very porous sandstone is, how- 
ever, not very durable in cold climates, as the stone absorbs large 
quantities of water, which, in consequence of the expansion 
accompanying the act of freezing, produces a gradual but 
progressive disintegration. 

The application of paint to the walls, either within or with- 
out, almost completely checks the transpiration of air through 
the walls, thus limiting natural ventilation. Calcimining, on 
the other hand, offers very little obstruction to the passage of 
air. Wall-paper is about midway between paint and lime- 
coating in its obstructive effect on atmospheric transpiration. 

Newly-built houses should not be occupied until the walls 
have become dry. Moisture in the walls is probably a not 
infrequent source of ill health; it offers favorable conditions for 
the development of fungi (possibly of disease-germs), and, by 
filling up the pores of the material of which the walls are 
composed, prevents the free transpiration of air through 
them. 

Moisture of the walls is sometimes due to the ascent of 
the water from the soil by capillary attraction. This can be 



174 TEXT-BOOK OF HYGIENE. 

prevented by interposing an impervious layer of slate in the 
foundation- wall. 

Where the moisture is due to the rain beating against the 
outside walls, and thus saturating them if composed of porous 
materials, a thorough external coating of impervious paint will 
prove a good remedy. 

IV. — INTERIOR ARRANGEMENTS. 

A. Size of Booms, and Ventilating and Heating Arrange- 
ments. — The rooms in dwelling-houses should never be under 
2| metres in height from floor to ceiling. In sleeping-rooms 
the initial air-space should never be less than 35 cubic metres 
for adults, and 25 cubic metres for children under 10 years of 
age. Provision must be made for changing this air sufficiently 
often to maintain it at its standard of purity; i.e., less than 7 
parts of carbon dioxide per 10,000. The details for accomplish- 
ing this will vary with the architects' designs, the material of 
which the house is constructed, the climate, and the season. 
The principles laid down in the section on ventilation (Chapter 
I) should be adhered to. In cold weather the air should be 
warmed, either before its entrance into the room or afterward, by 
stove or fire-place. Gal ton's jacketed stove, or fire-place, seems 
to answer this purpose admirably. The details of the heating 
apparatus must be left to individual taste, or other circum- 
stances. It may be noted, however, in passing, that the pre- 
vailing method of heating houses by means of hot air is objec- 
tionable for various reasons ; partly, because the air is usually too 
dry to be comfortable to the respiratory organs ; partly, because 
organic matter is frequently present in large proportions, and 
gives the air an offensive odor when the degree of heat is high 
enough to scorch the organic matter. Both these objections 
are, however, removable ; the first, by keeping a vessel of water 
constantly in the furnace, so that the hot air can take up a 
sufficient proportion of vapor in passing through, and, the second, 
by having the furnace made large enough so that the tempera- 



INTERIOR ARRANGEMENTS. 



175 



ture need never be raised to a very high degree. Heating by 
hot water or steam is preferable to the hot-air furnace. Both 
of these methods are, however, more expensive. 

Where special ventilating arrangements are necessary, air- 



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Fig. 6. 

a, a, sash • 6, 6, window-jambs ; c, c, window- 
sill. This cut represents the view from 
within the Bury Ventilator, in operation. 
It is broken away at one end to show the 
sash raised above the outer holes to admit 
the air. 



Fig. 7. 

a, a, sash. This cut represents the view from 
without the Bury Ventilator, in operation. 
The sash is broken away to show the ven- 
tilator behind, with the fresh air passing 
in. 



inlets may be inserted at appropriate points in the walls of the 
room, facing toward the air. A simple arrangement is that known 
as the Bury Ventilator, shown in Figs. 6 and 7. It consists 
of a wooden block interposed between the bottom of the lower 



176 



TEXT-BOOK OF HYGIENE. 



window-sash and the window- frame. The air passes into the room 
through the openings in the block, as shown in the illustration. 
The separation of the upper and lower sashes, when the ventilator 




is in place, also adds to the efficiency of the ventilation, as the 
air passes in through the space so formed. 

A cheaper ventilator can be made by simply tacking a strip 



INTERIOR ARRANGEMENTS. 177 

of canvas, binders' board, or manilla paper, 20 to 25 centimetres 
wide, across the lower portion of the window-frame, and then 
raising the sash 10 to 15 centimetres. The air will pass in 
under the lower and between the lower and upper sashes and 
pass upward toward the ceiling and then gradually diffuse itself 
through the room. In summer a counter-opening may be ob- 
tained for the escape of foul air by lowering the upper sash, 
while in winter a stove or fire-place will furnish a good exit. 

Fig. 8 shows the probable course of the air-currents in a 
room ventilated by means of a fresh-air inlet near the ceiling 
and an open fire-place. A is the inlet ; C the fire-place ; G the 
floor ; F, ceiling ; E E, flues. 

B. Internal Wall- Coating. — A point of considerable im- 
portance in the outfitting of dwelling-houses is the material 
used for coating or decorating the inside of the walls. Green 
paint and green-colored wall-papers should be rejected. The 
reason for avoiding this color is the following : Bright-green 
pigments and dyes are largely composed of some compound of 
arsenic, which becomes detached from the wall or paper when 
dry. and, being inhaled, produces a train of symptoms which 
have been recognized as chronic arsenical poisoning. Many 
cases have been reported in which serious and even fatal poison- 
ing has been produced in this way. 1 It would be advisable, 
therefore, to discard all bright-green tints in paints and orna- 
mental paper-hangings. 

C. Lighting. — Provision should be made in all dwelling- 
houses for an abundant supply of sunlight. Every room should 
have at least one window opening directly to the sun. It is not 
sufficient to give an ample window-space, which should be in 
the proportion of one to five or six of floor-space, but the im- 
mediate surroundings of the house must be taken into account. 
Thus, close proximity of other buildings, or of trees, may pre- 
vent sufficient light entering a room, although the window- 

1 Arsenic in Certain Green Colors, F. W. Draper. Third Annual Report Mass. State 
Board of Health, 1872, pp. 18-67. 

12 



178 TEXT-BOOK OF HYGIENE. 

space may be in excess of that required under ordinary 
circumstances. 

Some form of artificial light will also be needed in all 
dwellings. Certain dangers are necessary accompaniments of 
all available methods of artificial illumination. The danger 
from fire is, of course, the most serious. This danger is prob- 
ably least where candles are used, and greatest w 7 here the more 
volatile oils (kerosene, gasolene) are employed. The use of 
candles results in pollution of the air by carbon dioxide and 
other products of combustion to a greater degree than when 
other illuminating agents are used ; they also give out a larger 
amount of heat in proportion to their power of illumination. 
Kerosene gives a good light when burned in a proper lamp, and 
is cheap, but the dangers from explosion and fire are consider- 
able. The danger from explosion can be greatly reduced by 
always keeping the lamp filled nearly to the top, and never fill- 
ing it near a light or fire. The danger of explosion is increased 
when the chimney of the lamp is broken, as then the tempera- 
ture of the metal collar, by which the burner is fastened to the 
lamp, is rapidly raised 1 and the oil vaporized. If, at the same 
time, the lamp is only partially filled with oil, the space above it 
is occupied by an explosive mixture of air and the vapor of the 
oil. If this is heated to a sufficient degree an explosion will 
take place. 2 

The use of coal-gas is probably attended by less danger 
than the lighter oils, but by more than other means of illumina- 
tion. In addition to the dangers from fire and explosions, which 
are inevitable accompaniments of defects in the fixtures, the 
escaping gas is itself exceedingly poisonous from the large 
amount of carbon monoxide it contains. It is, in fact, a very 
frequent occurrence in large cities that persons are killed by the 
inhalation of gas which has escaped from the fixtures or was 

1 H. B. Baker, in Report Mich. State Board of Health, 1876, p. 48. 

2 See an instructive paper by Prof. R. C. Kedzie, in Report Mich. State Board of Health 
for 1877, p. 71 et seq. 



INTERIOR ARRANGEMENTS. 179 

allowed to escape from the burner through ignorance. That 
variety of illuminating gas known as "water-gas" is more dan- 
gerous to inhale than coal-gas owing to the larger proportion of 
carbon monoxide contained in it. The "natural gas" used as a 
fuel and illuminant in some places in the United States is espe- 
cially dangerous from the total absence of odor. The gas may 
escape in large quantity and fail to give notice of its presence 
except by an explosion, if ignited, or by producing asphyxia in 
those who incautiously venture into the air permeated by it. 

The electric light (Edison's incandescent system) is prob- 
ably open to less objection on the score of danger than any 
other of the illuminating systems mentioned. There is no trust- 
worthy evidence that the electric light has any unfavorable in- 
fluence on the vision, although Regnault supposed it would have 
a bad effect upon the ocular humors on account of the large 
proportion of the violet and ultra-violet rays it contained. In 
order to remove this objection Bouchardat advised the wearing 
of yellow glasses by those compelled to use this light for close 
work. The advantages of the incandescent light, besides the 
brilliant white light it gives, are that it is steady and does not 
produce any heat, nor does it pollute the air with carbon dioxide 
and other products of combustion. Professor von Pettenkofer 
has recently shown experimentally that the pollution of the air 
by the products of combustion is very much greater when gas 
is used than where the electric light is employed. The electric 
arc-lights are extremely dangerous on account of the high poten- 
tial maintained in the wires, and the difficulty of thoroughly 
insulating the latter. Many deaths have occurred from this 
source, and, unless a method is discovered and adopted by 
which the voltage of the arc-light current can be greatly dimin- 
ished without decreasing the efficiency of the light, this method 
of lighting must soon be given up in cities, owing to its danger, 
not only to those directly brought in contact with the conductors, 
but to others who may indirectly get in the way of the errant 
current. 



180 TEXT-BOOK OF HYGIENE. 

In writing, sewing, reading, or other work requiring a con- 
stant use of accurate vision, the light, whether natural or artifi- 
cial, should fall upon the object from above and on the left side. 
Hence, windows and burners should be at least at the height 
of the shoulder and to the left of the person using the light. 

Increased ventilation facilities must be provided where arti- 
ficial light (except the electric light) is used to any extent. It 
has been calculated that for every lighted gas-burner 12 to 15 
cubic metres of fresh air per hour must be furnished in addition 
to the amount ordinarily required in order to maintain the air 
of the room at the standard of purity. 

V. — WATER-SUPPLY. 

The water-supply of a dwelling-house should be plentiful for 
all requirements, and its distribution should be so arranged that 
the supply for every room is easily accessible. Where prac- 
ticable, water-taps should be placed on every floor, both for 
convenience and for greater safety in case of fire. It is also a 
result of observation that personal habits of cleanliness increase 
in a direct ratio with the ease of obtaining the cleansing agent. 
The inmates of a house where water is obtainable with little 
exertion are much more likely to be cleanly in habits than 
where the water-supply is deficient or not readily procured. 

VI. — HOUSE-DRAINAGE. 

Provision must be made for the rapid and thorough removal 
of waste-water and excrementitious substances from the house. 
This is most easily and completely accomplished by well-con- 
structed water-closets and sinks. Water-closets should, however, 
not be tolerated in any room occupied as a living- or bed- room. 
It would doubtless be very much more in accordance with sani- 
tary requirements to have all permanent water-fixtures, water- 
closets, and bathing arrangements placed in an annex to the 
dwelling proper. In this way the most serious danger from 
water-closets and all arrangements having a connection with a 



HOUSE-DRAINAGE. 181 

cess-pool or common sewer — permeation of the house by sewer- 
air — could be avoided. 

Water-closets, however, presuppose an abundant supply of 
water. Unless this can be obtained and rendered available for 
flushing the closets, soil-pipe, and house-drain, the dry-earth or 
pail system should be adopted. Privies should not be coun- 
tenanced. Experience in several large cities of Europe has 
demonstrated 1 that the pail system can be adopted with advan- 
tage and satisfactorily managed even in large communities. 

As house-drainage may be considered the first and most 
important link in a good sewerage system, a brief description 
will be here given of the details of the drainage arrangements 
of a dwelling-house. The rapid and complete removal of all 
faecal and urinary discharges, lavatory- and bath- wastes, and 
kitchen-slops must be provided for. For these purposes are 
needed, first, water-closets and urinals, wash-basins and bath- 
tubs, and kitchen- or slop- sinks ; second, a perpendicular pipe, 
with which the foregoing are connected, termed the soil-pipe; 
and, third, a horizontal pipe, or house-drain, connecting with the 
common cess-pool or sewer. 

A. Water- Closets — There are five classes of water-closets 
in general use. They are the pan-, valve-, plunger-, hopper-, and 
washout- closets. 

Pan-closets are those found in most old houses containing 
water-closet fixtures. Just under the bowl of the closet is a 
shallow pan containing a little water, in which the dejections 
are received. On raising the handle of the closet, the pan is 
tilted and the water at the same time is turned on, which washes 
out the excrement and sends it into or through the trap between 
the closet and the soil-pipe. It will be readily understood that 
the space required for the movement of the pan — the " container," 
as it is termed — is rarely thoroughly cleansed by the passage of 
water through it. Faecal matter, paper, etc., gradually accumu- 
late in the corners of the container, and, as a consequence, pan- 

1 See Chapter v, p. 139. 



182 TEXT-BOOK OF HYGIENE. 

closets are always, after a brief period of use, foul. There are 
other defects in the construction of the pan-closet which render 
it untrustworthy, but the one especially pointed out — the impos- 
sibility of keeping it clean — is enough to absolutely condemn its 
use, from a sanitary point of view. It is decidedly the worst 
form of closet that can be used. 

Valve-closets are merely modifications of the pan-closet. 
The bottom of the bowl is closed by a flat valve, which is held 
in its place by a weight. By moving a lever the valve is turned 
down, allowing the excreta to drop into the container. The only 
differences between the pan- and valve- closets are that in the 
latter a flat valve is substituted for the pan of the former, and 
that this allows the container to be made smaller. Otherwise, 
there are no advantages in the valve-closet. Considered from a 
sanitary stand-point, the valve-closet is no worse than the pan- 
closet, and but very little, if any, better. 

The third variety, or plunger-closet, has several marked 
advantages over the two just described. The characteristic 
feature of the closets of this class is that the outlet, which is 
generally on one side of the bowl, is closed by> a plunger. This 
bowl is always from one-third to one-half full of water, into which 
the excreta fall. On raising the plunger, the entire contents of 
the bowl are rapidly swept out of the apparatus into the soil- 
pipe, the bowl thoroughly washed out by a sudden discharge of 
water, and, on closing the outlet with the plunger, the bowl is 
again partly filled with water. An overflow attachment prevents 
accumulation of too large a quantity of water in the bowl. This 
overflow, however, sometimes becomes very foul and objection- 
able. The Jennings, Demarest, and Hygeia are types of this 
class. The principal objection is that the plunger sometimes 
fails to properly close the outlet, allowing the water to drain out 
of the bowl, and thus destroying one of its principal advantages. 
The mechanism is also somewhat complicated and likely to get 
out of order. 

The hopper-closet consists of a deep earthenware or enameled 



HOUSE-DRAINAGE. 



183 



iron bowl, with a water-seal trap directly underneath. The 
excreta are received directly into the proximal end of the trap, 
and when the water is turned on the sides of the bowl are 
washed clean and everything in the bowl and trap swept directly 
into the soil-pipe. There is no complicated mechanism to get 
out of order, the trap is always in sight, and the entire appa- 
ratus can always be kept clean and inoffensive, as there are no 
hidden corners or angles for filth to lodge. This form of closet 
is, all things considered, one of the best for general use. 




Fig. 9.— The "Dececo" Closet. (New Form.) 

The " wash-out " closets are of various shapes, some having 
the trap in the bowl itself, others having a double water-trap. 
They are generally simple in construction, and not likely to get 
out of order. They do not present any decided advantages over 
the simple hopper, although at the present time they are more 
used than any other form of closet. Of the recent improvements 
in this form of closet may be mentioned the "A. G. M.," 1 shown 

1 Manufactured by the Myers Sanitary Depot, New York. 



184 



TEXT-BOOK OF HYGIENE. 




Fig. 10— The "A. G. M." Closet. 



HOUSE-DRAINAGE. 185 

in view with cistern in Fig. 10, and in section in Fig. 11, and 
the " Dececo," Fig. 9, invented by Col. George E. Waring. 
In the latter the automatic siphon principle, so ingeniously used 
by Rogers Field in the construction of the automatic flush-tank, 
is applied to the scouring of a water-closet. Practical experi- 
ence for six or seven years has demonstrated the great usefulness 
of this closet. If the delivery of water from the flushing-cistern 
is properly regulated, at first rapid to thoroughly wash out the 



Fig. 11.— Sectional View op "A. G. M." Closet. 

closet and connections, and then slow to re-establish the proper 
depth of seal in the trap, the closet should be thoroughly satis- 
factory in its working. 

Water-closets should not be inclosed in wooden casings, as 
is almost universally done. Everything connected with the 
closet, soil- and drain- pipes, water-supply, and all joints and fix- 
tures should be exposed to view so that the defects can be imme- 
diately seen and easily corrected. By laying the floor and back 
of the closet in tiles or cement, such an arrangement can even 



186 TEXT-BOOK OF HYGIENE. 

be made ornamental, as suggested by Waring, 1 who says that a 
closet " made of white earthenware, and standing as a white 
vase in a floor of white tiles, the back and side walls being 
similarly tiled, there being no mechanism of any kind under 
the seat, is not only most cleanly and attractive in appearance, 
but entirely open to inspection and ventilation. The seat for this 
closet is simply a well-finished hard-wood board, resting on cleats 
a little higher than the top of the vase, and hinged so that it may 
be conveniently turned up, exposing the closet for thorough 
cleansing, or for use as a urinal or slop-hopper." 

Where the arrangement here described is adopted, extra 
urinals are unnecessary and undesirable. Where they are used 
they should be constantly and freely flushed with water, other- 
wise they become very offensive. The floor of the urinal should 
be either of tiling, slate, or enameled iron. 

B. Water- Supply for Closets. — The water-supply for flush- 
ing water-closets should not be taken directly from the common 
house-water supply, but each closet should have an independent 
cistern large enough to hold a sufficient quantity of water for a 
thorough flushing (20 to 30 litres) every time the closet is used. 
The objections to connecting the water-closet directly with the 
common house-supply are, that there is often too little head of 
water to properly flush the basin; and, secondly, if the water 
be drawn from a fixture in the lower part of the house, while 
the valve of a water-closet in an upper floor is open at the same 
time, the water will not flow in the latter (unless the supply- 
pipe is very large), but the foul air from the closet will enter 
the water-pipe, and may thus produce dangerous fouling of the 
drinking-water. Hence, separate cisterns for each water-closet 
should always be insisted upon. 

The arrangement of these cisterns is often difficult to com- 
prehend. Fig. 12 shows the interior arrangement of one form. 
The ball-shaped float, «, cuts off the supply when the tank is 
full, while opening the valve, &, by means of the crank, c, dis- 

* Sanitary Condition of New York City, Scribner's Monthly, vol. xxii, No 2, June, 1881. 



HOUSE-DRAINAGE. 



187 



charges the water. The rounded annex, c?, contains enough 
water to partly rill the closet-bowl and trap after the contents 
have been washed out by the rapid flush. 

C. Traps. — Every water-closet, urinal, wash-basin, bath- 
tub, and kitchen-sink should have an appropriate trap between 
the fixture and the soil-pipe. The trap should be placed as 
near the fixture as practicable, as pointed out above; in the 

best forms of water-closet the bottom of the closet itself forms 

* 

part of the trap. 




Fig. 12.— Flushing Cistern for Water-Closets. 

Traps differ in shape and mechanism. The simplest and 
usually efficient is the ordinary S-trap (Fig. 13). This trap is 
of uniform diameter throughout, and has no angles for the lodg- 
ment of filth. A free flush of water cleanses it perfectly, and 
it rarely fails to furnish a sufficient obstruction to the passage 
of sewer-air from the soil-pipe, unless the water has evaporated, 
or been forced out under a back-pressure of air in the soil-pipe, 
or been siphoned out, and thus the seal broken. 



188 TEXT-BOOK OF HYGIENE. 

The D-trap and bottle-trap are objectionable on account 
of the great liability of becoming fouled by filth lodging in the 
corners, while in the mechanical traps, like Bowers' ball-valve 
trap, CudelTs trap, and others of this class, there is always 
danger of insufficient seal by filth adhering to the valve, and 
thus preventing its exact closure. 

Most of the traps now furnished by the dealers in plumbers' 
supplies have an opening in the highest part for attaching a 
vent-pipe. It has been found that the seal in most traps can be 
broken by siphonage, if the pressure of air on the distal side 
(the side toward the soil-pipe) of the trap is diminished, or, on 
the other hand, by increase of pressure in the soil-pipe the 
water in the trap may be forced back into the fixture, and thus 
sewer-air enter the room. By providing for a 
free entrance and exit of air to the trap this 
>**%. breaking of the seal can be prevented. The 
/ f~\ \ ventilation of traps is, however, an evil, as it 
L ^^ 7 furnishes an additional means of evaporation, 

and when the fixture is not in frequent (daily) 
use the seal is sooner broken. The elaborate 
extra system of ventilation of traps, so generally 
insisted upon by plumbers and sanitary engineers, is unnecessary. 
If the soil-pipe is of the proper size and height, siphonage of 
traps will not be likely to occur. The waste-pipe connecting 
the fixture and the soil-pipe should be as short as possible; in 
other words, all water-closets, urinals, baths, and lavatories 
should be placed as near the soil-pipe as practicable, in order to 
have no long reaches of foul waste-pipe under floors or in 
rooms. 

Dr. E. S. McClellan has recently invented a trap which 
obviates many of the objections urged against all previous de- 
vices, and is intended to meet the defects of the S and other 
traps. It consists of a body containing a light, inverted cup, with 
its edges resting in an annular groove containing mercury, which 
forms an absolute seal against the escape of sewer-air. When 



KiG. 13.— S-TRAP. 



HOUSE-DRAINAGE. 



189 



a slight diminution of pressure occurs on the sewer side of the 
cup, the greater external pressure lifts the cup out of the 
mercury and permits a free inflow of air until the wonted 
equilibrium is re-established, when the cup drops back into the 
mercury by gravity, and effectually closes the trap against any 
outflow. With this trap siphonage of the seal is impossible. 
Fig. 14 shows this trap with the cup down, and Fig. 15 with 
the cup raised, allowing inflow of air. 

For an ordinary wash-bowl or bath-waste (which should 




Fig. 14.— Sectional View of Vent, with 
Cup in Normal, Position. 



Fig. 15.— Sectional View of Vent, with 
Cup Lifted Out of the Mercury 
by the Inflowing Current of Air 
Indicated by the Arrows. 



always be trapped), the Connolly globe- trap, shown in Figs. 16 
and 17, is an excellent fixture. It is impossible, under ordinary 
circumstances, to break the seal by siphonage. 

D. The SoiJ-Pipe. — The vertical pipe connecting the 
water-closets and other fixtures with the house-drain is called 
the soil-pipe. It should be of iron, securely jointed, of an equal 
diameter (usually 10 centimetres) throughout, and extend from 
the house-drain to from 1J to 2- metres above the highest point 
of the house. The connections of all the waste-pipes from 
water-closets, baths, etc., should be at an acute angle, in order 



190 



TEXT-BOOK OF HYGIENE. 



that an inflow at or nearly at right angles may not produce an 
obstruction in the free passage of air up and down the soil-pipe. 
The diameter of the soil-pipe, at its free upper end, should not 
be narrowed; in fact, according to Col. Geo. E. Waring, the 
up-draught is rendered more decided if the upper extremity of 
the soil-pipe is widened. 1 The internal surface of the pipe 
should be smooth, and especial care should be taken to prevent 
projections inward at the joints; otherwise, paper and other 





Fig. 16.— Connolly Globe-Trap. 



Fig. 17.— Globe-Trap Attached to Basin. 



matters will adhere to the projections, and gradually obstruct 
the pipe. 

E. The House-Drain. — The horizontal or slightly inclined 
pipe which connects the lower end of the soil-pipe with the 
sewer or cess-pool, the point of final discharge from the house, 
should be of the same diameter and material as the soil-pipe. 
The joints should be made with equal care, and the pipe should 
be exposed to view throughout while within the house-walls. 



1 Am. Architect, p. 124, Sept. 15, 



HOUSE-DRAINAGE. 191 

If sunk below the floor of the cellar it should be laid in a 
covered trench, so that it may be readily inspected. The junc- 
tion between the vertical and horizontal pipe should not be at a 
right angle, but the angle should be rounded. The drain-pipe 
should not be trapped. This is contrary to the advice of sanitary 
authorities generally, but the author thinks it unadvisable to trap 
the drain-pipe. There should be no obstruction to the outflow 
of sewage from the house, and a trap in the drain-pipe is of no 
avail against the passage of sewer-air from the sewer or cess- 
pool into the soil-pipe, if the pressure of the air in the former 
is increased. Furthermore, if the passage of air backward and 
forward between the sewer and the external air at a sufficient 
height (above the roofs of houses, for example) is free and 
unobstructed, the sewers (or the cess-pool, as the case may be) 
will be better ventilated than if an obstruction to such free 
circulation, in the form of a trap, be placed in the drain-pipe. 

Nearly all sanitary authorities direct that an opening for 
the admission of fresh air — " fresh-air inlet" — should be made 
in the drain-pipe, before its connection with the sewer or cess- 
pool. This is done with the view of having a constant current 
of fresh air entering near the base of the soil-pipe and passing 
upward through it. Theoretically the current ought always to 
pass in this direction. Practically, however, the current is 
found, at times, to pass the other way, and the foul air from the 
soil-pipe may be discharged into the air near the ground, where 
it would be much more likely to do harm than when discharged 
high up in the air beyond the possibility of being breathed. 

OFFICIAL SUPERVISION OF THE SANITARY ARRANGEMENTS OF 

DWELLINGS. 

In most cities and towns the municipal authorities have 
provided for an official inspection of buildings, to prevent neglect 
of precautions against fire and other manifest dangers to life. 
It is only very recently, however, that the authorities of some 
of the larger cities in this country have enacted laws to prevent 



192 TEXT-BOOK OF HYGIENE. 

improper construction of house-drainage works. Although none 
of these laws or ordinances cover the subject completely, yet 
their proper enforcement must result in great advantage. 

Within the past few years, following the example of Edin- 
burgh, volunteer associations have been organized in various 
cities of this country, with the object of securing constant expert 
inspection and supervision of the drainage arrangements of 
dwellings and other necessary sanitary improvements. 

The good results accomplished by the Newport Sanitary 
Protection Society, the New Orleans Auxiliary Sanitary Associa- 
tion, and other similar bodies attest the usefulness of such 
organizations. 

[The following works are recommended to the student 
who desires a fuller knowledge on the subjects treated in this 
chapter : — 

W. H. Corfield, Dwelling-Houses, Their Sanitary Construction and 
Arrangements, N. Y., 1880. — Wm. Paul Gerhard, House Drainage and 
Sanitary Plumbing, Fourth Report State Board of Health of R. I., 
1881. — Eliot C. Clarke, Common Defects in House-Drains, Tenth Annual 
Report Mass. State Board of Health, 1879.] 



QUESTIONS TO CHAPTER VI. 

Construction of Habitations. 

Why should the principles of hygiene be observed in the construc- 
tion of dwellings ? What relation is there between badly-constructed 
and overcrowded dwellings in cities? Between overcrowded dwellings 
and the death-rate, either general or from contagious diseases ? What 
class of persons are especially affected by overcrowding and unsanitary 
conditions of their dwellings ? 

What points should be taken into consideration in building a house ? 
What things are to be sought and what avoided in selecting a site ? On 
what kind of soil should the house be built ? How far should the ground- 
water be below the surface, even at its highest ? What must be known 
about a soil to determine whether it is sanitarily suitable for building 
purposes? What is the usual judgment concerning sites on granite, 
trap, or metamorphic rocks ? What if they have been disintegrated ? 
What regarding those on the clay slate? Limestone and magnesian 
limestone? Chalk? Sandstone? Gravel? Sands? Clays and alluvial 
soils? Cultivated lands? Which of the above is probably the best, on 
general principles, for the site for a dwelling ? Where a site is wet or the 
soil is impure, what must be clone ? What is the minimum depth at which 
drains for the soil-water should be laid ? How else may the drying of the 
soil be promoted? How should a cellar or basement over an impure soil 
be paved ? What precaution should be observed in building a house 
against a hill ? 

What are some of the materials of which the walls of a house may 
be built ? What are the advantages of good brick ? Why should very 
porous sandstone not be used for building purposes in cold climates? 
What is the effect of paint upon house-walls ? Has calcimining or white- 
washing the same effect ? Has wall-paper? How soon should newly-built 
houses be occupied ? To what are moist walls sometimes due, and how 
may they be obviated ? 

What should be the minimum height of rooms in dwelling-houses ? 
How much air-space should there always be in sleeping-rooms for adults 
and children ? What is the standard of purity of the air that should be 
maintained constantly? What are the objections to heating by hot-air 
furnaces, and how may- these objections be avoided ? How may a room 
be ventilated without expensive apparatus ? 

What colors should be avoided in wall-paper and paints for inside 
work, and why? What should be the proportion of window-space to 
floor-space, and what other points should be observed in the day-lighting 
of rooms ? What are the forms of artificial light used for household 

13 (193) 



194 QUESTIONS TO CHAPTER VI. 

illumination, and what are the dangers accompanjang each ? What are 
some of the especial advantages of the incandescent electric light? 
From what direction should the light come for writing, reading, etc. ? 
Why must there be increased ventilation where artificial lights (except 
incandescent electric) are used ? How much fresh air per hour is needed 
to properly dilute the impurities produced by burning illuminating gas ? 

What points are to be observed regarding the water-supply of a 
dwelling ? Why should it be both abundant and convenient ? 

How are waste-waters and excrementitious matters most readily 
removed from a house ? Where would it be best to have all fixtures, 
etc., of a house-drainage system located, if possible? What do water- 
closets, etc., presuppose? If this cannot be had, what system should be 
adopted instead ? For what must a proper house-drainage system pro- 
vide ? What are the component parts of such a system ? 

Where should water-closets never be located ? What five classes of 
water-closets are there? Which of these are most objectionable, and 
why ? Describe briefly the construction of a pan- and a valve- closet. 
In what way is a plunger-closet better than a pan- or valve- closet? 
Wherein is it sanitarily imperfect? Why is the hopper-closet one of the 
best ? What two kinds of hopper-closet are there ? What can be said 
of the wash-out closets? What is the principle of siphon closets ? Why 
should water-closets and other fixtures not be inclosed in wooden casings ? 
How may the surroundings of such closets and fixtures be further im- 
proved ? Why should the water-supply for closets not be taken directly 
from the house-supply ? ■ How much should the flushing cistern hold? 

What are traps ? Where should they be located ? How many 
should there be in any system of house-drainage ? What is the simplest 
form of trap ? What are its advantages ? Upon what does the value of 
a trap depend ? What is to be avoided in the selection of a trap ? What 
is meant by siphonage ? How can this be prevented ? To what part of 
the trap is the vent-pipe to be attached ? Where should the other end 
of the vent-pipe open ? How else may the seal of a trap be broken ? 
What is the principle of McClellan's anti-siphon trap? 

How long should the waste-pipe connecting the fixtures with the 
soil-pipes be ? What is the soil-pipe ? Of what dimensions should it 
be? Where should its upper extremity end ? What other precautions 
should be observed in regard to the soil-pipe ? 

What is the house-drain ? What care must be observed in the laying 
of it ? What can you say regarding a trap between the house-drain and 
sewer? If a trap is thus located, what else must there be between the 
trap and the house, and why ? What can be said regarding the official 
supervision of sanitary arrangements in dwellings ? 



CHAPTER VII. 

Construction of Hospitals. 

SITE. 

If the choice of a site for the habitations of healthy per- 
sons is a matter of vital importance, as was pointed out in the 
last chapter, it needs no argument to impress upon the reader 
the actual necessity of choosing a site with wholesome surround- 
ings for a habitation for the sick. In selecting a site for a hos- 
pital, therefore, it is of prime importance to avoid a location 
where unsanitary influences prevail. 

While a hospital should always be easily accessible, it is 
not desirable that it should be in a noisy or crowded part of a 
city. Where a hospital is primarily designed for the reception 
of accident or " emergency " cases, it is, of course, necessary to 
have it near to where accidents are likely to occur. In a city 
this will probably be in the most crowded and noisy part. 

The direction of the prevailing winds from the city should 
be avoided in selecting a site for a hospital. 

Free admission of sunlight and air must be secured to all 
parts of the hospital. An elevated location is therefore desir- 
able, although exposure to violent winds must, if possible, be 
avoided. 

The soil upon which a hospital is built should be clean, 
easily drained, with a deep ground- water level, not liable to 
sudden oscillations. The neighborhood of a marshy or known 
malarious region should be avoided. 

THE BUILDINGS. 

The building area must be large enough to permit the 
construction of buildings in accordance with the modern recog- 
nized principles of hospital construction. Overcrowding is not 

(195) 



196 TEXT-BOOK OF HYGIENE. 

permissible, either of the grounds by buildings or of the build- 
ings by patients. 

Having determined the number of patients for whom pro- 
vision is to be made and the character of the diseases to be 
treated, an estimate must be made of the area necessary for a 
hospital. Taking into account all the buildings needed, the 
area required will be — for two or more storied buildings — not 
less than 30 square metres per bed. If one-story buildings 
are to be erected more space will be required, and if infectious 
diseases are to be treated in the hospital the above space-allowance 
must be doubled or trebled. In the new Johns Hopkins Hos- 
pital, in Baltimore, the area occupied by the buildings is 56,000 
square metres, and provision is to be made for 300 patients. 
This, covering, of course, the area occupied by the administra- 
tion building, nurses' home, kitchen, dispensary, operating and 
autopsy theatre, laundry, etc., gives an area of 187 square metres 
per bed. The actual allowance of floor space per bed is 11^ 
square metres ; for patients with infectious diseases the space- 
allowance is nearly treble, being 29 square metres. 

Within recent years the principles of hospital construction 
have undergone considerable modification. While formerly 
a large hospital consisted usually of one large, two or more 
storied building, in which all the various departments were 
comprised under one roof, the aim has recently been to scatter 
the wards as much as practicable consistent with reasonable ease 
of supervision and administration. Under the former plan, with 
large wards connected by common corridors and stairways, ease 
of administration was primarily secured; in the latter, the 
most important object of a hospital, " a place for the sick to get 
well in," is more nearly attained. While many hospitals are 
still being constructed on the old plan, of a single block of 
several stories in height, nearly all sanitary authorities are 
agreed that the plan of separate pavilions of one or, at most, 
two stories, in which the buildings are entirely disconnected, or 
connected only by means of an open corridor for convenience of 



THE HOSPITAL BUILDINGS. 197 

administration, is best for the patients, and, leaving out of 
account the cost of the ground, is also the most economical. 

The recent development of the pavilion system of hospitals 
may be attributed largely to the success obtained in treating the 
sick and wounded in the simple barrack hospitals during the 
late war between the States. The army barrack hospital is the 
original type of the pavilion hospital of the present day. 

Each pavilion consists of one or two wards, containing 
from ten to thirty beds altogether. In each pavilion or ward is 
also a bath- and wash- room, water-closet, dining-room, scullery, 
attendants' room, and sometimes a day-room for patients able 
to be out of bed. 

The two-story pavilion is built on the same plan, and is 
generally adopted in cities, or where economy of space is desir- 
able for financial reasons, and where no infectious diseases are 
treated. Where practicable, one-story pavilions should always 
be adopted, as they are more easily heated, ventilated, and 
served than two-storied buildings. 

When a number of pavilions or wards are connected by a 
corridor with each other, and with a central or administration 
building and other service buildings, the aggregation constitutes 
a modern pavilion block-hospital. The Johns Hopkins Hos- 
pital, already referred to, is a model hospital of this class, and 
its plans should be studied in detail by all who are more par- 
ticularly interested in hospital construction. The general wards 
are in one- and two- story buildings, connected by a corridor with 
each other and with the administration and service buildings. 
In addition to two buildings containing private rooms and small 
wards for patients able to pay for the extra accommodations, 
there is a line of pavilions running from east to west. The 
corridor cuts all the pavilions near the north ends of the build- 
ings, separating the ward almost entirely from the service part 
of the building. This arrangement leaves the south, east, and 
west fronts of the wards entirely exposed to the sun's rays, — 
a very important advantage. The kitchen and laundry are at 



198 



TEXT-BOOK OF HYGIENE. 



opposite angles of the grounds, while the autopsy building is 
placed in the extreme northeast corner of the grounds, as far 
from all the wards as practicable. 

The free space between the separate pavilions should be at 



WOLFE ST. 



R L 

o t I 

id 

ST— fipffl H 1 F 

u 

C B 



BROAfc v |/AY~ 



3 [ 



Fig. 18.— Plan of Johns Hopkins Hospital. 

A. Administration Building. B. Female Pay-Ward. C. Male Pay-Ward. D. Male Surgical Ward. 
E. Female Surgical Ward. F. Male Medical Ward. G. Female Medical Ward. H. Gynaecological 
Ward. I. Isolating Ward. K. Kitchen. L. Laundry. N. Nurses' Home. O. Dispensary. R. Patho- 
logical Building. S. Stable. U. Amphitheatre. X. Apothecary's Building. Y. Bath-House. 



least twice the height of the building. In the Johns Hopkins 
Hospital, the space is 18 metres between the one-story common 
wards, which are 11 metres in 
ground to the ridge of the roof. 



height from the surface of the 



VENTILATION AND HEATING. 199 

VENTILATION AND HEATING. 

The cubic space (initial air-space) per bed in the wards 
should not be less than 1500 to 2000 cubic feet (42 to 56 cubic 
metres), and for surgical or lying-in cases and contagious dis- 
eases, 70 cubic metres should be allowed. The ventilating 
arrangements should secure an entire change of the air two to 
three times in an hour. 

In most sections of the United States, natural ventilation 
can be relied on to keep the air in hospital wards pure (assum- 
ing, of course, the proper construction of the buildings). The 
windows, doors, and walls are important factors in securing this 
ventilation. Hence, especial care is to be paid to their con- 
struction and arrangement. 

Many German, French, and English authorities on hospital 
building urge the importance of making the walls impervious 
by cement, glass, or paint. The peculiar odor known as " hos- 
pital odor," it is asserted, cannot be prevented in any hospital 
in which the floors, walls, and ceilings are not absolutely imper- 
vious. The American practice is generally in favor of walls 
which permit transpiration of air. In the experience of the 
author the imperviousness of the walls is not necessary to secure 
freedom from hospital odor. It remains a question for serious 
consideration whether the diminution of natural ventilation 
would not counterbalance any good resulting from non-absorp- 
tive walls. 

The interior of the walls should be perfectly smooth and 
plain; no projections, cornices, or offsets of any kind are per- 
missible. The desirability of this restriction was clearly ex* 
pressed over a hundred years ago by John Howard : " From 
a regard to the health of the patients, I wish to see plain, white 
walls in hospitals, and no article of ornamental furniture intro- 
duced." 1 

Windows should run quite to the ceiling, and should not 
be arched, but finished square at the top. There should be one 

1 An Account of the Principal Lazarettos of Europe, etc., p. 57. London, 1791. 



200 TEXT-BOOK OF HYGIENE. 

window for every two beds. The window-sash should be double 
to retain heat, and the lights heavy, clear glass. Ventilation 
can be promoted by raising the outer sash from below and 
lowering the inner one from above. The insertion of a Sher- 
ringham ventilator at the top of the inner sash will aid in giving 
the incoming air-current an upward direction. 

Heating is best accomplished by introducing hot air from 
without, or by stoves or fire-places in the centre of the wards. 
Where hot air is introduced from without, it should be heated 
by passing it over steam- or hot- water coils, and not by passing 
it through a furnace, which may produce super-heating and 
excessive dryness of the air. 

In a series of experiments by Dr. Edward Cowles at the 
Boston City Hospital, 1 the air was heated to 32° by passing it 
over steam-coils. It was admitted to the wards by numerous 
inlets 30 centimetres square. The best velocity for ventilating 
and warming purposes was found to be 54 metres per minute. 
Exit openings were in the ceiling, and it was found best to 
make them large, as by this means the rapidity of exit currents 
is reduced. 

Where the warming of the ward must be accomplished by 
stoves or fire-places in the ward, the best plan, for square and 
octagon wards, is to have a large central chimney with arrange- 
ments on the four sides for fire-places or stoves. This chimney 
can also be used as a very efficient ventilating shaft throughout 
the year by a device put in practice by Mr. John R. Neirnsee, 
architect of the Johns Hopkins Hospital. 2 In oblong wards, 
two or more large stoves, placed at equal distances along the 
centre of the wards, will heat the wards effectually. 

Floors should be made of tiles, slate, or oak or yellow-pine 
lumber. If wood is used, it should be well seasoned, perfectly 
smooth, and all joints accurately made. The floor should be 
kept constantly waxed to render it impervious to fluids. 

1 Report of the Massachusetts State Board of Health for 1879, pp. 231-248. 

2 Hospital Construction and Organization : Plans for Johns Hopkins Hospital, p. 335 
et aeq. New York, 1875. 



VENTILATION AND HEATING. 201 

The space between the floor and ceiling below should be 
filled with some fire-proof non-conducting material, such as 
cement or hollow bricks, in order to isolate each floor or ward 
as much as possible from others, both to prevent transmission 
of noise and extension of fire. 

All corners and angles on the inside of the building should 
be rounded to facilitate the removal of dust. 

In cleaning up, care should be taken not to stir up the 
layers of dust too much by active sweeping or dusting. The 
floors, furniture, door- and window- casings should be wiped off 
with damp cloths. Soiled bedding, clothing, dressings, and 
bandages must be promptly removed from the ward. Mat- 
tresses and other bed-clothing should not be shaken in the ward. 1 

Water-closets or (where the dry method of removal of ex- 
creta is in use) earth- or pail- closets should be placed where 
they can be easily reached by the patients, but the apartment in 
which they are placed must not open directly into the ward. 
The entrance to this apartment should be from the corridor 
or, better still, from the open air. The ventilation of water- 
closets should be independent of and entirely distinct from 
that of the ward or other part of the hospital building. 

It is, of course, unnecessary to more than call attention to 
the vital importance of the prompt removal of all excreta, both 
solid and liquid, from the ward or hospital building. To at- 
tempt disinfection of excreta and allow them to remain in the 
ward after being voided is a pernicious practice, which should 
under no circumstances be permitted. All utensils for the re- 
ception of excreta, bed-pans, etc:, should be immediately emptied 
and thoroughly cleansed. 

Urinals are not advisable ; the simple hopper-closet with 
hinged, hard-wood seat, as described in Chapter VI, is sufficient. 

A bath-room and lavatory should be attached to every 
ward. It should be placed in the service building, and be 

X A Wernicb : Ueber Verdorbene Luft in Krankenrseumen. Volkmann's Samml. Klin. 
Vortr., No. 179, p. 24. 



202 TEXT-BOOK OF HYGIENE. 

easily accessible to the patients. There should also be portable 
bath-tubs in order that baths may be given in the wards when 
necessary. 

Every large general hospital should also have a special 
apartment or building where baths of various kinds, such as 
medicated, vapor, Turkish, and Russian baths, could be given. 
In lying-in hospitals, special arrangements for giving vaginal 
and uterine douches must also be furnished. 

A daily water-supply of at least 450 litres per bed should 
be provided. The water should be easily accessible from the 
wards and various parts of the service building. 

All water-closets, soil- and waste- pipes must be properly 
trapped ; all joints must be properly made and all sewer con- 
nections made on the most improved plans. All work of this 
sort should be properly tested before being accepted, and 
frequently inspected afterward. 

No sewer or house-drain should be laid under a ward. 

A disinfecting chest for disinfecting soiled clothing, bed- 
ding, dressings, etc., should be placed in the basement of the 
ward, and connected with the latter by an iron chute, closing 
perfectly by an iron top. The best and most convenient disin- 
fectant is steam. This is also the best means to destroy vermin 
in clothing and bedding. 

It is questionable whether a nurse's room should be 
attached to a hospital ward. The nurse's place, when on duty, 
is in the ward itself, not in a room separate from it. Where 
there is a nurse's room, it should not be furnished with sleeping 
arrangements, for this is a strong temptation to neglect of duty 
on the part of the nurse. A nurse not on duty should not be 
permitted to remain about the ward. 

A ward-kitchen should be in the service building, where 
articles of food can be kept hot or cold when necessary, and 
where special dressings, cataplasms, hot water, etc., can be pre- 
pared. A small gas-stove only should be allowed in the ward- 
kitchen, as the regular meals of the patients are prepared in the 



ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 203 

central kitchen, which should be totally detached from the 
hospital. The ward-kitchen can be easily utilized as a nurse's 
room, and in a small hospital can also be used as a store-room 
for the patients' body- and bed- linen and clothing. 

The dining-room for patients able to be out of bed should 
be in the service building. A room with a good light and well 
ventilated and heated should be selected for this purpose. In 
the intervals between meals this room could be used as a day- 
room for such patients as should be out of bed, but who are not 
able to be in the open air. 

A dead-house, containing a dead-room, autopsy-room, and 
a room fitted up for rough microscopic and possibly photo- 
graphic work, is a necessity to every well-appointed general 
hospital. The dead-house should be entirely separate from the 
ward buildings. 

The kitchen should be separate from the other buildings, 
and in large hospitals should also be the central station for the 
heating arrangements, if hot water or steam are to be used. The 
laundry may be connected with it. The kitchen should be con- 
nected with the wards by means of a covered corridor to avoid 
exposure in carrying the food to the wards. 

The administration building should contain office-rooms 
for the superintendent and resident physician, pharmacy, library, 
reception-rooms for visitors, living-rooms for one or more assist- 
ants, and dwellings for the superintendent and resident physician. 

THE ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 

The general management of a hospital should be under the 
direction of a superintendent, who, besides being a medical man, 
should be especially qualified by study and experience for the 
work. The superintendent of a large hospital should not be 
expected to perform any of the routine professional work in the 
wards, but he should be responsible for the service, both profes- 
sional and lay, in the hospital. He should be the financial 
officer, and in all other things concerning the hospital his 



204 TEXT-BOOK OF HYGIENE. 

judgment should decide. He should have sufficient assistance 
to permit all necessary duties to be promptly performed. For 
this purpose he should have a secretary, or clerk, who should 
not be a medical man; otherwise the attention of the latter 
might be withdrawn from his clerical duties to the more inter- 
esting professional work in the hospital. The plan advocated 
by some authorities, to have two superintendents for large hos- 
pitals, — one of whom shall be a medical man and direct only the 
professional work of the hospital, while the other shall have 
charge of the administrative functions, — does not commend itself 
to the author. It involves a division of responsibility which will, 
in nearly all cases, eventually lead to differences of opinion 
likely to prove unfavorable to the best interests of the hospital. 

It is customary in this country to appoint as resident physi- 
cians and surgeons in hospitals, recent graduates, whose functions 
are usually limited to carrying out the directions of the visiting 
physicians and surgeons, and sometimes to act on their own 
responsibility in emergencies. This system has some advantages 
for the physicians, but is usually detrimental to the best interests 
of the patients. The resident medical officer in a large hospital 
should always be a thoroughly qualified, experienced physician, 
capable of deciding promptly when the occasion arises, and he 
should be responsible to the superintendent for the proper per- 
formance of his professional duties. Necessarily, a physician 
with the qualifications indicated, would demand a very much 
larger salary than is usually paid resident physicians, but it 
should be understood that no hospital in which the good of 
the patient is the first consideration can be conducted on a cheap 
basis. 

Visiting physicians and surgeons and all resident medical 
officers should be chosen with reference to their general and 
special qualifications for the duties expected of them. It would 
seem to be a good plan to make the selections for subordinate 
positions, at least, by competitive examination. 

The sick in a hospital should be properly classified. Male 



ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 205 

and female patients should, of course, be treated in separate 
wards. A primary classification into medical, surgical, and 
obstetrical cases or wards is also indicated. Infectious dis- 
eases, such as typhoid fever, erysipelas, cholera, yellow fever, 
croupous pneumonia, etc., should not be treated in the same 
wards with rheumatism, Bright 's disease, cardiac and nervous 
disorders, or simple digestive derangements. It is questionable, 
however, whether it is advisable to make a very elaborate classi- 
fication of the various diseases except in very large hospitals. 

An accurate record, made at the time of observation, and 
not written from memory afterward, should be kept of the his- 
tory and progress of every case. The record should show not 
merely the symptoms and diagnosis, but the medical and hy- 
gienic treatment. In most hospitals where such records are 
kept the entries are made either in a simple memorandum-book 
or in a more or less complicated case-record. A simple form 
of case-record has been devised by Surgeon- General Walter 
Wyman,of United States Marine-Hospital Service, which seems 
to possess advantages that render its general adoption desirable. 

In hospitals where cases of surgical diseases and injuries are 
received, a special apartment should be fitted up as an operating- 
room. Operations should not be performed in a ward in the 
presence of other patients. 

[The following works are recommended for additional study 
upon this subject: — 

Hospital Construction and Organization ; New York, 1875 (espe- 
cially the essays of Drs. Billings, Folsom, and Stephen Smith). — Kran- 
kenanstalten, by L. Degen, in Y. Pettenkofer und Ziemssen's Hand- 
buch der Hygiene. — Spital,by C. B6hin,in Healenc3'clopadie d. ges. Heil- 
kunde, Bd. XII. — General Principles of Hospital Construction, by F. H. 
Brown, in Buck's Hygiene and Public Health, vol, i. — Schumburg, 
Hygienische Grundsatze beim Hospitalbau.] 



QUESTIONS TO CHAPTER TIL 
Construction op Hospitals. 

What would govern you in selecting a site for a hospital ? What 
will go to determine the building area ? In calculating the area required 
for buildings, what relation has it to the number of beds in the hospital ? 
In the wards, what should be the actual minimum floor-space for each 
bed for non-infectious and for infectious diseases ? What is the differ- 
ence in the principles of modern hospital construction and of those for- 
merly in vogue ? What are some of the advantages of the modern plan ? 
What was the prototype of the present system? How many wards 
should each pavilion contain at the most ? How many beds in each 
ward ? What conveniences should there be in each ward or pavilion ? 
What is meant by a pavilion block-hospital ? What space should there 
be between the separate pavilions ? 

What cubic space per bed should there be in the ordinary wards ? 
What cases need more, and how much ? How often should the air be 
entirely changed in the wards ? Should the walls be pervious or imper- 
vious to the passage of air ? How should the walls be finished ? How 
many windows should there be in each ward? How high should 
they be ? 

What is the best way to heat a hospital ward ? How should hot air 
be warmed ? If a ward is to be warmed by fire-places or stoves, how 
should they be arranged ? 

Of what materials should the floors be made ? How should they be 
treated ? What should there be between ceilings and the floors above ? 
Why? How should the corners and angles of floors and ceilings be 
finished ? 

How should the wards be cleaned ? What should be done with 
soiled bedding, etc. ? 

Where should the water-closets, etc., be located ? How should they 
be ventilated? 

How much water should be furnished per bed? Why should no 
sewer or house-drain be laid under a ward ? Where should the nurses' 
rooms be? Where the ward kitchen and dining-room? What is the 
administration building for, and what should it contain ? What officers 
are necessary for the management of a hospital ? What are their duties ? 
How should the resident physicians be qualified and selected? How 
should the sick be classified, and what wards should there be in a general 
hospital ? Mention some of the details that should be noted in the case 
records. 

(206) 



CHAPTER Vin. 

Schools. 

The hygiene of schools comprises the consideration of the 
sanitary principles underlying the construction of school-houses 
and school- furniture ; the proper amount of time to be devoted 
to study at different ages ; the special diseases of school-children, 
their causes, and means for their prevention. 

CONSTRUCTION OF SCHOOL-HOUSES. 

In the construction of school-houses the same hygienic 
principles are applicable as in dwelling-house construction. The 
selection of a site for the school-building should command the 
same careful consideration that is necessary in determining upon 
a site for a dwelling. Proximity to marshes and other unsan- 
itary surroundings should be avoided. If the soil is damp it 
should be properly drained,* and all sources of insalubrity in the 
neighborhood avoided or, if possible, removed. 

School-houses should not be over three stories high ; cor- 
ridors and stairways should be wide, straight, and well lighted. 
All stairs should be securely built, and be guarded with ample, 
strong railing. All doors should open outward to permit ready 
egress and reduce the danger of accident in panics from any 
cause. 

In addition to the study- or recitation- rooms, provision 
should be made for play and calisthenic-exercise rooms. Well- 
lighted and ventilated side-rooms should be provided for the 
reception of outside clothing, umbrellas, overshoes, etc. These 
articles should not be kept in the recitation- or study- rooms. 

Floors should be made of accurately-joined flooring, and 
rendered impervious by oil or parafTme coating. 

(207) 



208 TEXT-BOOK OF HYGIENE. 

Appropriate measures must be employed to prevent the 
permeation of the building by ground-air. 

The inside walls of school-rooms may be tinted a neutral 
gray, or light blue or green. Ceilings should be white. Walls 
and ceilings should not be painted, but lime-coated to permit 
free transpiration of air. 

Schools should be so constructed as to permit of ready 
heating and ventilation, cleaning, and keeping clean. In large 
schools the method of heating will usually be by furnace-heated 
air, although a better method would probably be by steam- 
or hot-water pipes. 

The ventilation of school-rooms must be carried out on the 
principles indicated in Chapter I. With careful and intelligent 
teachers, natural ventilation will give better satisfaction than a 
complicated artificial system. Where windows and doors must 
be largely depended upon for ventilation, the Bury window ven- 
tilator, illustrated on a previous page, will give satisfactory results 
unless the school-room is overcrowded. Opening the doors and 
windows when the pupils are out of doors — flushing the rooms 
with fresh air — is an excellent aid, and is even useful in cases 
where the most elaborate artificial system of ventilation is in use. 

A model study-room, according to modern views, should 
be about 9 to 10 metres long, not over 7 metres wide, and 4 to 
4^ metres high. Such a room could be easily lighted by win- 
dows on one side only, and readily heated and ventilated. It 
would also enable the teacher to exercise a close supervision 
over his pupils. In a room of this size forty pupils would be a 
proper number, although fifty could be accommodated. The 
initial air-space for each pupil would be 5.60 cubic metres if 
there were fifty pupils in the room, and 7 cubic metres if 
there were only forty. This would be slightly reduced by the 
allowance for the teacher. 

It is believed that study-rooms should face toward the 
north. The light entering from the north side of a building 
would be equable during a whole day. While a larger window 



CONSTRUCTION OF SCHOOL-HOUSES. 209 

surface would be necessary than with an easterly or southerly 
exposure, it is held that the light, being devoid of all glare, 
would be more effective. Where the light is admitted on the 
east, south, or west sides of the building, the direct entrance of 
the sun's rays must be prevented by curtains, by means of which 
the amount and proper distribution of the light is regulated 
with difficulty. 

The windows of the school-room should reach from about 
the height of the pupil's shoulder (when seated) to nearly or 
quite to the ceiling. Arches or overhanging cornices over the 
windows should be avoided, as they cut off much light. For 
the same reason the near proximity of other high buildings 
and of trees should be avoided in selecting a site for a school- 
house. The window area should be not less than one-fifth of 
the floor area, otherwise the light will be deficient. 

The light should be admitted only from the left side of the 
pupil. When admitted from the right side the shadow cast by 
the pen in writing interferes with good vision ; if admitted 
directly in front of the pupil, the glare of the light will injuri- 
ously affect the eyes ; while, if it enter from behind, the book 
or paper of the pupil will be so much in shadow as to compel 
him to lean so far to the front in bringing his eyes nearer to 
book or paper that nearsightedness is very likely to be devel- 
oped. Furthermore, if the light is admitted into the room at 
the backs of the pupils, the eyes of the teacher are liable to 
suffer from the constant glare. 

In a school-room of the dimensions above stated, a row of 
windows on one side, forming an area of glass one-fifth of the 
floor-space, will thoroughly and satisfactorily illuminate the 
room, with the least unfavorable influence upon the organs of 
vision. It is advisable, therefore, to always insist on this 
arrangement of lighting of school-rooms. Where artificial 
light is used in a school-room, it should be in the proportion 
of one burner to every four pupils. All burners should be 
provided with chimneys and vertical reflectors. 

14 



210 TEXT-BOOK OF HYGIENE. 

Water-closets and privies should not be placed in cellars or 
basements. This would seem to be self-evident, and yet in 
many city school-houses these places of retirement are in this 
unsuitable location. When it is considered that large schools 
are frequently warmed by hot air taken from the cellar, it 
furnishes an additional reason to avoid this location for water- 
closets. On the contrary, the custom, in some country schools, 
of placing the privy at a considerable distance from the school- 
room and in an exposed situation, is almost equally reprehen- 
sible, as the pupils, especially girls, are prone to neglect obeying 
the calls of nature, from which neglect many disorders arise. 

In a recently-introduced system of ventilation and excre- 
ment removal for schools, the closets are in the basement, and 
the excrement, as voided, is rapidly dried by a current of air, 
and the odor in this way quickly destroyed. Unfortunately, in 
thus drying the excrementitious matter, micro-organisms may 
be taken up in the air-currents and carried into the school-rooms. 

SCHOOL FURNITURE. 

Desks should be slightly sloping, the edge nearest the pupil 
being about 1 inch (2.5 centimetres) higher than his elbows. 
The front edge of the seat should project a little beyond the 
near edge of the desk, so that a plumb-line dropped from the 
latter should strike the seat near its front edge. If the seat is 
not thus brought slightly under the desk, the pupil is compelled 
to lean forward in writing, which position prevents proper ex- 
pansion of the chest and increases the blood-pressure in the 
eyes, — a condition promotive of near-sightedness. 

Seats should be only high enough so that the feet rest flat 
upon the floor. If they are higher, a foot-board must be pro- 
vided. Children should not be condemned to the cruelty of 
having their feet dangling " between heaven and earth " while 
they keep their seats. Seats and desks should be graded 
according to the sizes of the pupils — not their ages or standing 
in the class. 



SCHOOL FURNITURE. 211 

An ideal seat and desk would be one made to measure for 
each pupil, but this is manifestly impracticable, inasmuch as 
with the constant growth of the child the seats would be rapidly- 
outgrown. 

The desk shown in Fig. 19 * is adjustable to children of 
different sizes, and seems to solve the problem which has so long 
puzzled the school sanitarian. The desks are made for a single 
pupil and the seat and desk are independently adjustable. 




Fig. 19.— Adjustable School-Desk. (Front View.) 

The frame is of iron and the seat, back, and desk of hard-wood 
lumber. 

Blackboards should not be placed at a greater distance than 
10 metres from the farthest pupil. The ground of the board 
should be a dead black, without lustre. In writing exercises 
upon the board, care should be taken that the letters and figures 
are made sufficiently large, and with rather heavy strokes of the 
crayon, in order that they may be easily seen from the most distant 
part of the room. It has recently been demonstrated that a black 
letter on a white ground can be seen at a greater distance than 

1 Made by the Rushville School Furniture Company, Rushville, Ind., U. S. A. 



212 TEXT-BOOK OF HYGIENE. 

a white letter on a black ground. Hence, it might prove 
advantageous to the eye-sight of school-children to substitute 
for the present blackboard and chalk, a white board and black 
crayon. In some European lecture-rooms this plan has been 
adopted with satisfaction. 

AMOUNT OF TIME TO BE DEVOTED TO STUDY. 

Young children should not be kept at the same study or 
in the same position for long at a time. The exercises should 
be frequently varied. It is especially with children in the 
primary grades that care should be taken not to overburden 
their minds with too many hours of study, or too long con- 
tinuance at the same exercise. 

Children should not be placed in school much, if at all, 
before the completion of their 7th year. From 7 to 9 years 
they should be kept at their studies not longer than three hours 
daily; from 9 to 12 years four hours may be allotted them; and 
from 12 to 16 years they may be kept at mental work five to six 
hours daily. This does not mean that pupils are to be kept 
continuously at their studies during these hours, but that they 
should be neither compelled nor permitted to study longer than 
these periods each day. It is believed that these figures repre- 
sent the capacity for endurance in the majority of children, and 
they should be adopted in all schools where the largest return 
in mental acquirements is desired at the least expenditure of 
health. Excess of time expended in study is almost certainly 
followed by physical deterioration. " A little less brain : a little 
more muscle," for our children, is a legitimate demand that we 
may make of legislators and school-boards. 

Gymnastic exercises should form part of the daily routine 
in all schools. These exercises should take place, when practi- 
cable, in the open air. Playing, romping, laughing, and sing- 
ing should be encouraged, rather than the natural tendency 
to boisterous play restrained. It is especially desirable that 
female children should be encouraged to take part in these 



DISEASES OF SCHOOL-CHILDREN. 213 

diversions. The desire, on the part of many parents, to see 
little girls deport themselves as young ladies, before the time 
even when they write their age in two figures, is very rep- 
rehensible, and deserves the most unqualified condemnation. 
Moliere's satirical remark, " II n'ya plus d'enfants," seems to 
be literally true at the present day. 

DISEASES OF SCHOOL-CHILDREN. 

The principal diseases incident to school-life are myopia, 
spinal deformities, nervous and digestive disorders, pulmonary 
phthisis, and contagious diseases. It is believed that by judi- 
cious sanitary measures these can all be very much diminished 
and some entirely prevented. 

It has been shown by the examination of the eyes of school- 
children that near-sightedness increases progressively from the 
lowest to the highest classes. Children who enter school with 
an hereditary tendency to myopia, or who are, perhaps, already 
near-sighted to a slight degree, soon become more intensely 
myopic ; while others, who may be even hypermetropic on enter- 
ing school, will be found to have become near-sighted during 
school-life. In examinations of over 30,000 pupils of grammar 
and high schools in Germany, Austria, Russia, and Switzerland, 
it has been found that the average proportion of near-sightedness 
is a fraction over 40 per cent., varying, in the different classes, 
from 22 per cent, for the lowest to 58 per cent, for the highest 
classes. These figures represent the averages of all the ex- 
aminations made. In some particular schools, for example in 
the gymnasium (high school) of Erlangen, the percentage in the 
higher classes was 88 per cent., in the gymnasium of Coburg 
86 per cent., and in the gymnasium of Heidelberg the propor- 
tion of myopic students in the highest class is said to have 
reached 100 per cent, in 1877. In the primary schools the per- 
centage was found to be much lower. Recent investigations in 
the schools of Stockholm, by Widmark, show that among 
school-children examined under 7 years of age there was no 



214 



TEXT-BOOK OF HYGIENE. 



myopia. In the higher classes the myopia increases not only 
in degree, but in frequency. The diagrams, Figs. 20 and 21, 
show graphically the increase in degree and frequency of 
myopia in the several school-classes. These observations show 
that the number of myopic individuals bears a constant relation 
to the intensity of use of the visual organs. The results of the 
observation of different observers in different countries also 




Fig. 20.— Myopia According to School-Classes— Boys. 

uniformly point to the conclusion that not only does the number 
of near-sighted pupils increase as the higher classes are reached, 
but the degree of myopia increases likewise. Thus, a pupil 
who may have only a moderate degree of myopia on entering 
the school will have myopia in a higher degree as he advances 
in his classes. Erismann found, on re-examining the same 
pupils annually, that in six years 13.14 per cent, of those ex- 
amined had developed myopia from emmetropia, while in 24.57 



DISEASES OF SCHOOL-CHILDREN. 



215 



per cent, of near-sighted pupils the degree of myopia had 
increased. 1 

The principal causes of the prevalence of near-sightedness 
in schools are badly-arranged or insufficient light, bad air, over- 
heating of the school-rooms, improper construction of desks 
compelling children to lean forward while reading or writing, 
and badly-printed text-books. The use of small type, poor 
paper, and bad press-work in text-books is very reprehensible. 
The type technically known as Long Primer is the smallest that 



Class 






II 



in 



IV v 



VI 



WVMTX 



Class. 

M 



frf> 



m 



irillll'llllllllllll ■■■•■■■Illlllll ■■■■lilllll'.HI'ill 

■ .J.tll.M»IIIIHIIIIIIIIIIIIIIIIIIIIirillllinHMIIIH>'H-^'« 




Fig. 21.— Myopia According to School-Classes— Girds. 

should be used in text-books. That badly-arranged light and 
improper seats are causes of myopia has been shown by Flor- 
schutz in his examinations of the pupils in the public schools 
of Coburg. He found that in the newer schools, in which the 
light and seats are better arranged, the percentage of near-sight 
decreased. The average percentage of those examined in 1874 
was 21, while in 1877 it had been reduced to 15, 2 showing 

1 Erismann, Die Hygiene der Schule, in von Pettenkoffer und Ziemssen's Handbuch der 
Hygiene, n Th., 2 Abth., p. 30. 

9 Quoted by Cobn in Realencyclopaedie d. ges. Heilk., Bd. XII, p. 263. 



216 TEXT-BOOK OF HYGIENE. 

the great improvement due to the application of correct sanitary 
principles in the construction of school-houses. 

Defective hearing has recently been shown to be especially 
frequent among school-children. A Berlin aurist found 1392 
children out of 5902 (23.6 per cent.) suffering from ear disease 
of some kind. Dr. Samuel Sexton, of New York, and the late 
Dr. Chas. F. Percivall, director of music in the public schools 
of Baltimore, have arrived at similar results after examination 
of a large number of school-children. 

Spinal curvature is present in a large proportion of the 
children attending schools. Statistics are not very full upon 
this subject, but one author, Guillaume, states that he found 
lateral curvature of the spine in 218 out of 731 school-children, 
— a proportion of 29.5 per cent. This, of course, includes the 
slighter degrees of curvature, which cannot properly be termed 
a disease. Among 30,000 Danish school-children 13 per cent, 
had some variety or degree of spinal deformity. M. Eulen- 
burg 1 found that among 1000 persons with lateral curvature of 
the spine, the disease began in 887 between the ages of 6 and 
14; that is to say, during the years of school-life. Girls are 
affected more than ten times as often as boys, the proportion 
being 93.43 per cent, in the former and only 6.57 per cent, in 
the latter. 

The especial causes of spinal curvature occurring during 
school-life are improperly-constructed seats and desks and an 
improper position of the body. Many pupils habitually assume 
a " twisted " position, which is very liable to produce spinal dis- 
tortion in children of weak muscular development. The manner 
in which a desk that is too high for the pupil may produce 
spinal distortion is very well shown in Fig. 22. An improper 
position is more likely to be unconsciously assumed by girls than 
by boys. The clothing is responsible for this, for when the girl 
files into her place behind the desk, her clothing, hanging 
loosely about her, is swept back and forms a pad, upon which 

1 Realencyclopsedie d. ges. Heilk., Bd. XI, p. 564. 



DISEASES OF SCHOOL-CHILDREN. 



21 



she sits with one buttock. The greater elevation of her seat 
on chat side throws the spinal column out of the vertical line, 
which is compensated by a partial twisting of the trunk. The 
attention of teachers should be directed to this faulty habit, 
which can be easily corrected, and its consequences averted by 
timely interference. 

Nervous disorders are comparatively frequent among school- 
children. Headaches are often due to insufficient ventilation, 
improper food, bad digestion, and excessive mental strain. 
Defective light may also be the cause of headaches by causing 




Fig. 22.— Sho"W1ng Influence of a High Desk in Causing Spinal Curvature. 

ocular fatigue. Hysterical and imitative affections are not 
infrequent, and sometimes pass through entire schools, including 
even the teachers. Girls are, of course, more subject to this 
class of disorders than boys, but the latter are not entirely 
exempt. 

Derangements of the digestive organs are exceedingly 
frequent among school-children. They can generally be traced 
to the use of improper food. The eating of cold lunches should 
be discouraged as much as possible. 

Nuts, candies, pies, fruit-cakes, and, above all, pickles are 



218 TEXT-BOOK OF HYGIENE. 

most fruitful sources of digestive derangements of children. 
The absence of proper accommodations to enable children — 
especially girls — to answer the demands of nature are frequent 
sources of digestive and nervous disorders. 

The seeds of pulmonary consumption are frequently im- 
planted during school-life. A neglected cough ; bad ventilation, 
under which term may be comprised overheating and cold 
draughts, as well as polluted air; improper position of the 
body, excessive mental work, or underfeeding, may, any of 
them, be the starting-point of this fatal disease. 

Especial care should be taken to prevent the introduction 
or dissemination of contagious diseases through schools. The 
importance of this duty should be at all times impressed upon 
school-boards and teachers. In the first place, no child should 
be admitted within the door of the school-room unless it first 
presents undoubted evidence of protection against small-pox, 
either by having passed through a previous attack or by a 
proper vaccination. In case of an actual or threatened epidemic 
of small-pox the entire school, including teachers, should be 
vaccinated. 

Diphtheria has been shown to be frequently spread through 
the agency of schools. 1 This fatal disease demands especial 
precautions on the part of teachers and others involved in the 
management of schools, to prevent its introduction to these 
institutions. 

Children should not be admitted to school coming from a 
house where there is at the time, or has recently been, a case of 
contagious disease, such as small-pox, diphtheria, scarlet fever, 
or measles. At least four weeks should be allowed to elapse 
after the termination of such disease before a child from the 
infected house is re-admitted to the school. It goes without 
saying that no child having itself been sick with a contagious 
disease should be admitted to school until entirely restored to 

1 The Relations of Schools to Diphtheria and to Similar Diseases, H. B. Baker, Public 
Health, vol. vi, p. 107. 



DISEASES OF SCHOOL-CHILDREN. 219 

health. The aforesaid limit of four weeks is the briefest period 
allowable before the quarantine of the infected house (so far as 
the schools are concerned) can be relaxed. 

When a case of contagious disease has accidentally obtained 
entrance to the school, the pupils should be dismissed for the 
day, and the room thoroughly disinfected by means of sulphur, 
chlorine, or, what is better, scrubbing and spraying with solution 
of mercuric chloride. 

Teachers are not infrequently guilty of the grave impru- 
dence of sending pupils from the school to the house of an absent 
child to inquire the reason of the latter 's non-appearance at 
school. It frequently happens that the absent child is sick, and 
the messenger is invited to the sick-room to see his or her class- 
mate. There can be no room for doubt that scarlet fever, 
diphtheria, and measles have often been introduced into schools 
in consequence of such thoughtlessness on the part of teachers. 

In order to promote the proper hygienic management of 
schools, all teachers should be required to submit to an exami- 
nation in the principles and practice of hygiene, at least so far 
as school hygiene especially is concerned. This is a demand 
that school-boards could reasonably insist upon, and there can 
be no question that the improvement in the health of the pupils 
would amply justify the innovation. 

[Students may consult with advantage the following special 
articles : — 

D. F. Lincoln, School Hygiene, in Buck's Hygiene and Public 
Health, vol. ii, and Lomb Prize Essay on School Hygiene, Concord, 
N. H., 1887. — F. Erismann, Die Hygiene der Schule, in Yon Pettenkofer 
und Ziemssen's Handb. d. Hygiene, II, Th. 2 Abth. — Reuss, Schulbank- 
frage, in Realencyclopsedie d. ges. Heilk., Bd. XII. — H. Colin, Schul- 
kinderaugen, ibid. — C. J. Lundy, School Hygiene, Public Health, vol. 
ix. — Rohe, The Necessity of the Sanitary Supervision of Schools, Journ. 
Am. Med. Ass'n, Dec. 28, 1889. — Report of the Committee on School 
Hygiene to the American Medical Association, 1893.] 



QUESTIONS TO CHAPTER VIII. 

Schools. 

What does the hygiene of schools comprise ? What principles are 
applicable in the construction of school-houses ? What is to be sought, 
and what avoided, in the selection of a site ? 

What should be the limit of height for school-houses? What rooms 
are needed besides those for study or recitation ? What precautions must 
be observed regarding stairs, railings, and doorways ? How may the 
ground-air be kept out of the building ? What kind of floors should the 
various rooms have ? 

What will be probably the best means of heating a school-house? 
What is the usual method in large schools ? Which will usually give 
the best ventilation, natural or artificial? When and how may school- 
rooms be ventilated to advantage ? 

How large should an ordinary school-room be? What are the 
advantages of a room of this size ? How many pupils would this 
accommodate, and about how much air-space would each have ? Is this 
sufficient ? 

On which side of the room should the windows be, if possible? 
How should the seats and desks be arranged in relation to the windows ? 
What should be the relation of window-area to floor-area? How high 
should the windows be above the floor, and how near to the ceiling 
should the} T reach? What are the objections to windows on two sides 
of the room ? Will windows of the above dimensions properly illu- 
minate the room? How much artificial light will be needed for proper 
illumination? What should be the color of walls and ceilings? 

Where should the water-closets, etc., of a school be located? What 
supervision of these must be exercised? 

How high should school-seats be? What should be the relation of 
seat to desk, and how high should the latter be ? Why should the front 
edge of the seat be brought under the desk? 

How far should the black-boards be from the pupils ? On which side 
of the room ? How should the surface be finished? 

When should a child begin to go to school ? What is the maximum 
time advisable for daily study at the respective ages? What should be 
the length of lessons and recitations for each age ? What is an almost 

(220) 



QUESTIONS TO CHAPTER VIII. 221 

certain result of too long study-hours ? Should there be more than one 
session daily, and should recesses be abolished ? What should form 
part of the daily school-routine ? Should this be taken from the recess 
period, or should it be part of the school-work ? 

What are some of the diseases incident to school-life ? Can these 
be prevented ? Are they altogether due to school-life ? How does the 
proportion of cases of near-sightedness vary in school-children? Is the 
increase one of degree or of frequency ? What are the causes of this 
excess of myopia ? If these causes are avoided or corrected, will the 
prevalence of myopia decrease ? 

What other sense is defective among school-children? What 
physical deformity is very prevalent ? What are the special causes of 
this deformity ? Why is it apt to be more common among girls ? At 
what age is the deformity most apt to begin ? 

What nervous disorders are frequent among school-children? What 
are some of the causes of chronic headache ? What pupils are most 
subject to hysterical affections? What are some causes of nervous 
disorders ? Of digestive disturbances ? 

How may consumption or other forms of tuberculosis be due to the 
school-life? What precautions should be observed in regard to the pre- 
vention of the spread of infectious diseases among school-children ? 
What diseases are to be especially guarded against, and how shall this 
be done ? What should be the shortest limit of quarantine against a 
pupil that has had any one of these diseases ? If a case of infectious 
disease gains entrance to the school, what is to be done ? Why should 
teachers be required to pass an examination on the principles of lrygiene ? 



CHAPTER IX. 

Industrial Hygiene. t ^^ 

One of the most interesting chapters in the study of hygiene 
is that which treats of the relations of occupations to health and 
life. While it is unquestionable that certain occupations are 
intrinsically dangerous to health, there can be no doubt that in 
many instances incidental conditions not necessarily connected 
with the occupation are factors in the production of disease. 
Such factors are bad ventilation and other insanitary surround- 
ings, as well as in many cases want of sufficient or proper 
food. 

Occupations induce disease by compelling the workmen to 
inhale irritating, poisonous, or offensive gases, vapors, or dust ; 
or by causing the absorption through the skin or mucous mem- 
branes of irritating or poisonous substances. Changes of tem- 
perature, as exposure to great heat or cold, produce diseases 
which are, in some instances, characteristic. In another class 
of cases the excessive use of certain organs, as the nervous 
system, the eyes, the vocal organs, or various groups of muscles, 
produce characteristic morbid effects. Again, a constrained 
attitude while at work, a sedentary life, or occupations involving 
exposure to mechanical violence are recognized sources of dis- 
ease and death. 

The following table gives the mortality and average age at 
death of all decedents over 20 years of age whose occupation 
was specified, in the State of Massachusetts, for thirty-one 
years and eight months. The total number of decedents was 
144,954 ; the average age at death, 50.90 years. Subdivided 
into classes and individual occupations, the results are as 
follow : — 

(223) 



224 



TEXT-BOOK OF HYGIENE. 



Table XX. 

Occupations of Persons tchose Occupations were specified, and whose Deaths were 
registered in Massachusetts during a period of thirty-one years and eight 
months, ending with December 31, 187 4. 1 



Occupations. 



Class I. Cultivators of 
the Earth: Farmers, 
Gardeners, etc. . . . 

Class II. Active Me- 
chanics Abroad . . . 
Brick-makers . . . . 
Carpenters and Joiners 
Caulkers and Gravers 

Masons 

Millwrights 

Riggers 

Ship-carpenters . . . 

Slaters 

Stone-cutters 

Tanners 

Class III. Active Me- 
chanics in Shops . . 

Bakers 

Blacksmiths 

Brewers 

Cabinet-makers . . . 

Calico-printers .... 

Card-makers 

Carriage - makers and 
Trimmers 

Chair-makers .... 

Clothiers 

Confectioners .... 

Cooks 

Coopers 

Coppersmiths .... 

Curriers 

Cutlers 

Distillers 

Dyers 

Founders 

Furnace-men .... 

Glass-blowers .... 

Gunsmiths 

Hatters 

Leather-dressers . . . 

Machinists 

Millers . 

Musical-Inst. mkrs. . 



Number 

of 
Persons. 



31,832 



10,893 
106 

6,150 
180 

1,662 

118 

161 

873 

81 

1,025 
537 



16,576 

471 

2,402 

28 

781 

9 

39 

276 
138 

84 

85 
112 
927 
101 
366 
131 

27 
143 
361 
133 
132 
250 
356 
179 
2,097 
278 

33 



Average 
Age at 
Death. 



65.29 



56.19 
46.85 
53 33 
58.59 
50.33 
59.14 
52.25 
58.53 
40.99 
40.90 
50.36 



47.57 
47.04 
53.26 
47.11 
48.84 
52.11 
48.23 

48.21 
41.77 
56.50 
44.11 
40.82 
59.22 
45.89 
41.50 
39.21 
56.85 
45.17 
42.51 
43.42 
37.88 
48.86 
54.67 
47.23 
41.67 
57.14 
46.73 



Occupations. 



Nail-makers . . . . 
Pail- and Tub- makers 

Painters 

Paper-makers . . . 
Piano-forte-makers 

Plumbers 

Potters .... 
Pump- and Block 

makers . . 
Reed-makers 
Rope-makers 
Tallow-chandlers 
Tinsmiths . 
Trunk-makers 
Upholsterers 
Weavers . . 
Wheelwrights 
Wood-turners 
Mechanics (not speci 

fied) ....... 

Class IV. Inactive 
Mechanics in Shops 

Barbers 

Basket-makers . . . 

Book-binders .... 

Brush-makers . . . 

Carvers 

Cigar-makers .... 

Clock - and watch- 
makers 

Comb-makers .... 

Engravers 

Glass-cutters . . . . 

Harness-makers . . . 

Jewelers 

Operatives 

Printers 

Sail-makers 

Shoe- cutters . . . . 

Shoe-makers .... 

Silver or Gold smiths 

Tailors 

Tobacconists .... 

Whip-makers .... 

Wool-sorters .... 



Number 

of 
Persons. 



174 
5 

1,850 

288 

111 

131 

40 

89 

9 

248 

67 
375 

48 
124 
480 
507 

76 

2,015 



17,233 

403 

70 

150 

53 

90 

154 

100 
134 
124 

76 

423 

468 

2,138 

717 

217 

362 

9,772 

92 

1,393 

43 

99 

155 



1 Thirty-third Registration Report of Massachusetts, p. cvi et seq. 



INDUSTRIAL HYGIENE. 



225 



Table XX (continued). 



Occupations. 



Class V. Laborers (no 
special trades) . . . 

Laborers 

Servants 

Stevedores 

Watchmen 

Workmen in Powder- 
mills 

Class V I . Factors 

Laboring Abroad, etc. 

Baggage-masters . . . 

Brakemen 

Butchers 

Chimney-sweeps . . . 

Drivers 

Drovers 

Engin'rs and Firemen 

Expressmen 

Ferrymen 

Lighthouse-keepers . 

Peddlers 

Sextons 

Soldiers 

Stablers 

Teamsters ...... 

Weighers and Gaugers 
Wharfingers . . . . . 

Class VII. Employed 
on the Ocean .... 

Fishermen ...... 

Marines ....... 

Naval Officers .... 

Pilots 

Seamen 

Class VIII. Merck' ts, 
Financ'rs, Ag'ts, etc. 

Agents 

Bankers 

Bank Officers .... 

Boarding-House kprs. 

Book-sellers 

Brokers 

Clerks and Book-kprs. 

Druggists and Apoth- 
ecaries 



Number 

of 
Persons. 



28,058 
27,382 

389 
76 

193 

18 



15,977 

376 

49 

151 

75 

73 

198 

3,435 

255 



Average 
Age at 
Death. 



47.41 
47.49 
40.10 
52.09 
50.06 

39.67 



7,035 


36.29 


37 


34.08 


246 


26.44 


537 


50.19 


4 


34.50 


327 


38.88 


17 


49.29 


567 


38.77 


216 


41.30 


9 


53.78 


10 


60.40 


417 


45.18 


81 


59 94 


2,885 


28.37 


354 


42.54 


1,282 


40.35 


24 


60.67 


22 


50.00 


8,844 


46.44 


433 


42.82 


4 


41.25 


58 


50.00 


82 


60.38 


8,267 


46.45 



48.95 
46.76 
57.61 
55.14 
47.96 
53.05 
49.58 
35.93 

42.37 



Occupations. 



Gentlemen . 

Grocers . . 

Innkeepers . 

Manufacturers 

Merchants . 

News-dlrs. and Car'rs 

R. R. Agents or Con- 
ductors 

Saloon- and Restau- 
rant- keepers . . . 

Stove-dealers . . . . 

Telegraphers . . . . 

Traders 

Class IX . Profes- 
sional Men . . . . 

Architects 

Artists ....... 

Civil Engineers . . . 

Clergymen 

Comedians 

Dentists 

Editors and Reprtrs. 

Judges and Justices . 

Lawyers 

Musicians 

Photographers . . . 

Physicians 

Professors 

Public Officers . . . 

Sheriffs, Constables, 
and Policemen . . 

Students 

Surveyors 

Teachers 

Class X. Females . 

Domestics 

Dress-makers .... 

Milliners 

Nurses 

Operatives 

Seamstresses . . . . 
Shoe-binders . . . . 
Straw-workers . . . 

Tailoresses 

Teachers 

Telegraphers . . . . 



Number 

of 
Persons. 



1,512 

517 

467 

1,375 

3,927 

27 

318 

299 

12 

5 

2,908 

5,175 

29 

186 

117 

965 

32 

114 

87 

18 

676 

266 

10 

1,166 

45 

437 

158 

288 

86 

495 

3,343 

1,037 

259 

136 

116 

703 

289 

48 

73 

233 

442 

7 



Average 
Age at 
Death. 



68.42 
47.59 
50.04 
51.23 
54.17 
41.22 

39.85 

40.90 
45.25 
28.80 
48.08 

50.81 
47.07 
44.18 
42.32 
58.57 
37 31 
41.61 
46.68 
64.11 
56.45 
41.59 
36.80 
54.99 
55.93 
55.37 

53.76 
23.23 
51.44 
41.79 

39.13 
46.64 
43.36 
39.42 
61.06 
27.82 
46.50 
43.12 
34 83 
47.49 
31.27 
24.43 



The above table cannot be absolutely relied upon for several 
reasons, the principal of which is that the table is incomplete. 
Many of the occupations are merely temporary, and persons are 



15 



226 TEXT-BOOK OF HYGIENE. 

constantly shifting from the pursuit of one calling to another 
Judges and lawyers, for example, should be included under one 
heading, while the class " students " should be excluded alto- 
gether. The table shows, however, very clearly, the relations of 
certain occupations to longevity. It is seen, for example, that 
agriculturists have the greatest expectation of life. Next to 
these come mechanics engaged out-of-doors. Professional men 
come next, and of these clergymen and members of the bar have 
the first and second places, respectively. The expectation of 
life of physicians is above the average, being nearly 55 years. 
Mechanics engaged in active work in-doors may expect to live 
3.70 years longer than those whose occupation requires them to 
retain a more or less constant position. 

Occupations which are accompanied by the formation of 
much dust, either inorganic or organic, are especially unfavor- 
able. They usually produce diseases of the respiratory organs, 
which may eventuate in phthisis. In the table it is seen 
that the average age at death of stone-cutters was 40.90 ; of 
cotton-factory operatives — male 39.16, female 27.82 ; 1 of cigar- 
makers, 38.36 ; and of cutlers, 39.21 years. The figures more 
or less closely approximate the conditions which have been 
shown to exist in England and on the Continent of Europe. In 
Sheffield, the workmen who grind and polish the cutlery, called 
" dry grinders," are said to suffer from a characteristic pulmo- 
nary affection termed "grinders' asthma" (emphysema) in the 
proportion of 69 per cent, of the whole number employed. The 
average duration of life of the needle-grinders of Derbyshire 
is 30.66 years. Among the cutlery-grinders of Solingen, in 
Rhenish Prussia, Oldendorff found 29 per cent, suffering from 
pulmonary affections, while the average age at death of the 
" dry grinders " was 40.7 years. 

1 These figures must be accepted with much reserve. While it is probable that the 
average age at death among women engaged in different occupations is less than that of men 
engaged in the same occupations, the figures in Table XX, Class X, cannot be used as a basis of 
comparison. So many women are annually withdrawn from the various occupations by mar' 
riage, which places them under different conditions, that the statistics of the occupations of 
women in the table are untrustworthy. 



OCCUPATIONS PREJUDICIAL TO HEALTH. 227 

OCCUPATIONS PREJUDICIAL TO HEALTH. 

The diseases of occupations may conveniently be divided 
into the following classes : — 

1. Diseases due to the inhalation of irritating or poisonous 
gases and vapors. 

2. Diseases due to the inhalation of irritating or poisonous 
dust. 

3. Diseases due to the absorption or local action of irritating 
or poisonous substances. 

4. Diseases due to exposure to elevated or variable temper- 
ature or atmospheric pressure. 

5. Diseases due to excessive use of certain organs. 

6. Diseases due to a constrained attitude and sedentary life. 

7. Diseases from exposure to mechanical violence. 

I. — DISEASES DUE TO THE INHALATION OF IRRITATING OR POISONOUS 

GASES OR VAPORS. 

Sulphurous-acid gas is used in various trades as a bleach- 
ing agent. In the manufacture of straw hats and in the drying 
or " processing " of hops this agent is extensively employed, 
and the people engaged in these industries frequently suffer 
from respiratory and digestive disorders. These are, however, 
rarely serious. If free access of air is allowed, the dangers to 
health in the above employments are very slight. 

Nitric-acid fumes may be dangerous to health when in- 
haled in a concentrated form, but very few cases are on record 
where any positively deleterious influence can be traced to this 
agent. 

Hydrochloric-acid fumes may prove deleterious to the work- 
men in soda manufactories, where the fumes are disengaged 
during the so-called " sulphate process." But the danger is 
probably slight. On the other hand, attention has recently been 
called to a peculiar effect of hydrochloric-acid fumes upon the 
workmen in fruit-canning establishments. The men who seal 
or " cap " the cans after being filled are the ones affected. The 



228 TEXT-BOOK OF HYGIENE. 

lesion has been described by Dr. W. Stump fForwood, who says 
concerning it : " The constant inhalation of the fumes of muri- 
atic acid, associated as they are with the lead solder, which the 
busy " capper " neglects to protect himself against, soon pro- 
duces inflammation of the mucous membrane of the nose, which 
finally results in ulceration. With some patients, after the 
removal of the cause and the application of proper treatment, 
recovery takes place after two or three months; but with those 
who have a scrofulous taint in then constitutions this ulceration 
is exceedingly intractable, and, in spite of all treatment, proceeds 
for months and even years, until the septum is finally perforated. 
And, strange to say, it is the common experience of those who 
have suffered that, as soon as perforation takes place, all the 
soreness and consequent annoyance disappears and the patient 
recovers, with, of course, a permanent opening in the nasal 
septum." 1 Dr. Forwood adds that anointing the nose, both 
within and without, several times a day, and avoidance of the 
acid fumes as much as possible, will prevent the peculiar affection. 

Ammonia rarely causes disturbances of health in work- 
men brought into contact with it. When present in the air in 
large proportion it may give rise to serious symptoms. As it is 
often used to prevent the poisonous effects of mercury (q. v.), care 
should be taken that the proportion of the vapor in the air of 
the work-room should not exceed 5 per cent. 

Chlorine gas is very deleterious in its effects upon the work- 
men brought in contact with it in the various industries in which 
it is employed. Nearly one-half of the workmen engaged in the 
manufacture of chlorinated lime and in bleaching become affected. 

The respiratory organs are principally attacked. Pneu- 
monia is exceptionally frequent. If an affected individual is 
predisposed to consumption the latter disease is soon lighted up, 
and quickly proves fatal. The effect of the inhalation of con- 
centrated chlorine is thus graphically described by Hirt 2 : " The 

lPhila. Med. and Surgical Reporter, June 30, 1883. 

2 Von Pettenkofer und Ziemssen's Handbuch der Hygiene, etc., II Th., 4 Abth., p. 30. 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 229 

workman suffers from violent cough and extreme dyspnoea. In 
spite of the aid of the auxiliary respiratory muscles, the entrance 
of air to the lungs is insufficient, and the widely-opened eyes, 
the pale-bluish color, and the cold perspiration plainly show the 
mortal agony of the patient. With this the pulse is small, the 
temperature decreased. Soon after removal from the impreg- 
nated atmosphere these phenomena disappear, and a few hours 
later the workman is found enveloped in chlorine and hydro- 
chloric-acid vapors in his accustomed place in the factory. The 
attacks seem to be but rarely fatal." 

The constant inhalation of an atmosphere strongly impreg- 
nated with chlorine produces a cachectic appearance, bronchial 
catarrh, loss of the sense of smell, and a prematurely aged appear- 
ance. When this stage of chronic chlorine poisoning has been 
reached complete health can rarely be re-established, even if 
the patients be entirely removed from the irritating atmosphere. 

Carbon monoxide is often present in the air of gas-works, 
iron smelting-works, and coke or charcoal furnaces. The work- 
men engaged in these industries often suffer with diseases of the 
respiratory organs, digestive disturbances, and general debility. 
Acute poisoning from carbon monoxide is relatively frequent, as 
already pointed out. 1 The prominent symptoms are at first vio- 
lent headache, dizziness, and roaring in the ears. These symp- 
toms are followed by great depression of muscular power, nausea, 
and vomiting. The vomited matters sometimes gain entrance 
into the trachea, and may thus produce strangulation « Uncon- 
sciousness, convulsions, and asphyxia rapidly succeed. Paral- 
yses of the sphincters and of groups of other muscles are often 
present. The pulse is at first somewhat increased, but soon 
becomes slower. The respiration is slow and stertorous, and the 
temperature falls from 2.5° to 3° C. (3° to 4° F.). Glycosuria 
often occurs. If death does not occur in the attack, the patient fre- 
quently suffers from great depression, both physical and mental ; 
loss of appetite, constipation, and various paretic conditions. 

1 See Chapter I, p. 29. 



230 TEXT-BOOK OF HYGIENE. 

The slow or chronic form of poisoning by carbon monoxide 
is characterized by headache, dizziness, slow pulse and respira- 
tion, nausea, and sometimes vomiting and purging. Loss of 
memory and diminution of mental activity are also said to be 
effects of the continued inhalation of air charged with carbon 
monoxide. 

Carbon dioxide is found as one of the constituents of the 
" choke-damp" in mines. There is reason to believe that this 
is often the source of ill health and death in miners, even where 
the symptoms of acute carbon-dioxide poisoning are not present. 
Hon. Andrew Roy 1 says that "it is more insidious than direct in 
its operations, gradually undermining the constitution and kill- 
ing the men by inches." Difficulty of respiration and weakness 
are the only symptoms calling attention to the pernicious effects 
of the gas. Where, however, the proportion of carbon dioxide 
is large, acute poisoning occurs. This is manifested by the 
following symptoms : Loss of consciousness and of the power of 
voluntary motion. In some cases there are convulsions ; in 
others the above symptoms are preceded by difficult respiration, 
headache, depression, drowsiness, or psychical excitement. Re- 
covery usually soon follows after removing the patient into a 
purer atmosphere. 

Vintners, distillers, brewers, and yeast-makers are said to 
suffer from the effects of carbon dioxide occasionally, but serious 
results from this cause are probably very infrequent. 

It may not be amiss to call attention here to another dan- 
gerous mixture of gases sometimes found in mines, and which 
is occasionally the source of appalling accidents. This is the 
so-called "fire-damp" or light carburetted hydrogen (CH 4 ). 
When this gas is mixed with atmospheric air in the proportion 
of 6 to 10 volumes per cent., the mixture becomes violently 
explosive if ignited. The danger does not cease with the explo- 
sion, however, for in this act the free oxygen present is consumed 

1 Third Annual Report State Mine Inspector of Ohio. Quoted in Buck's Hygiene and 
Public Health, vol. ii, p. 243. 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 231 

in the formation of carbon dioxide, and the workmen then die 
asphyxiated, or from the effects of " choke-damp." The dangers 
from "fire-damp" can be largely averted by thorough ventilation 
and by the use of the safety-lamp of Sir Humphry Davy, which 
gives warning of the presence of the gas and permits the work- 
men to escape before the explosion takes place. 

Sulphuretted hydrogen, when present in the air in large 
proportion, — as, for example, in privy-vaults, cess-pools, and 
sewers, — may produce serious or fatal poisoning. Formerly, 
when vaults were cleaned in the primitive way, these accidents 
were frequent; but at the present day, owing to improved 
methods of removing excreta, they are comparatively rare. The 
precautions advised in a preceding chapter 1 should be borne in 
mind when it is necessary for workmen to enter such places. 

The gases resulting from the putrid decomposition of organic 
substances, such as are found in tanneries, glue- and soap- works, 
and similar industries, are popularly believed to give rise to 
various diseases. There are no observations on record, however, 
to show that such is the case. As a matter of fact, the workmen 
engaged in the industries mentioned, seem to be exceptionally 
healthy, and to resist to a considerable degree the ravages of 
phthisis and epidemic diseases. 

Bisulphide of carbon is used in the arts principally in the 
process of vulcanizing India rubber, and for extracting oils from 
seeds and fatty bodies. The constant inhalation of the vapor 
of bisulphide of carbon produces a train of symptoms to which 
attention was first attracted by Delpech in 1856. The symp- 
toms have been observed frequently since that time. The follow- 
ing account is from Hirt 2 : — 

" Some days, or even weeks or months, after beginning this 
occupation, the workmen complain of a dull headache, becoming 
more severe toward evening. This symptom is soon followed by 
joint-pains, formication, and itching on various parts of the body. 
A more or less troublesome cough is present, but is not accom- 

1 Chapter I, p. 37. ■ Op. tit., p. 66. 



232 TEXT-BOOK OF HYGIENE. 

panied by any characteristic sputa. The respiration is regular, 
the pulse somewhat increased in frequency. During this time 
certain individuals exhibit a marked exaltation of their intel- 
lectual powers; they talk more than formerly, and show an 
interest in matters in which they at other times show no concern. 
There is, however, very rarely distinct mental disease. The 
sexual desires are increased in both sexes, menstruation becomes 
irregular, and the urine possesses a faint odor of bisulphide of 
carbon. In this manner several weeks or months pass away. 
Very gradually the psychical exaltation disappears, and a pro- 
found depression, melancholy, and discouragement succeeds, 
coupled with which is often loss of memory. Vision and hear- 
ing become less acute, and the sexual activity is completely 
destroyed. Anaesthetic spots appear on various parts of the body, 
and numbness of the fingers prevents the workman from perform- 
ing any fine work." 

The disease never proves fatal, but the normal condition 
of the individual is rarely re-established when the disorder has 
advanced to the extreme stages mentioned. 

Iodine and bromine vapors, when inhaled by workmen en- 
gaged in their preparation, produce symptoms of poisoning 
which are sometimes very serious. Acute iodic intoxication 
consists in severe laryngeal irritation, headache, conjunctivitis, 
and nasal catarrh. Occasionally there is temporary loss of con- 
sciousness. Chronic iodic cachexia is often found among the 
workmen. In certain cases atrophy of the testicles and gradual 
disappearance of sexual power has been observed. In the manu- 
facture of bromine, a form of bronchial asthma has been 
observed among those engaged in the establishment. No 
symptoms corresponding to those of chronic iodism have been 
observed among the workmen in bromine. 

The inhalation of the vapors of turpentine produces, in a 
considerable number of those constantly exposed to them, dis- 
eases of the respiratory organs, beginning with cough and, at 
times, resulting in consumption. In other cases derangement 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 233 

of the digestive organs, strangury, and, in a few cases, bloody 
urine have been observed. Nervous disturbances are rare after 
the inhalation of turpentine, and are limited to headache, roar- 
mg in the ears, or flashes of light before the eyes. 

Petroleum vapor, when inhaled in a concentrated state, pro- 
duces symptoms similar to those of anaesthetics. When exposed 
for a long time to diluted petroleum vapor, workmen sometimes 
suffer from chronic pulmonary catarrhs or from nervous de- 
rangements. Among the latter are disturbances of mental 
activity, loss of memory, giddiness, and headache. These symp- 
toms are, however, rare. More frequent are pustular or furuneu- 
lar affections of the skin, which are due probably to the direct 
irritant effect of the vapor. 

Lead poisoning is one of the most characteristic diseases of 
artisans. It attacks workmen engaged in the roasting and smelt- 
ing of lead ores ; in the manufacture of white and red lead and 
of lead acetate and chromate ; in type-making, in painting, and, 
in short, in all occupations in which the workman is compelled 
to inhale the vapor or dust of lead, or in which it is conveyed 
in some manner to the digestive organs. It is believed also that 
it can be absorbed by the skin and produce its poisonous effects 
upon the economy. The average duration of life in the roast- 
ing and smelting furnaces is -11 years ; of painters, as shown by 
Table XX, -15.07 years. Of the latter 75 per cent, are attacked 
by one of the forms of lead poisoning, colic being most frequent. 
In the manufacture of white lead more than half of the work- 
men suffer from lead poisoning during the first year, lead colic 
being present in 60 per cent, of all the cases. 

In most sugar-of-lead manufactories 60 per cent, of all 
the operatives constantly suffer from some form of lead 
poisoning. 

Poisoning has also been observed in workmen engaged in 
the manufacture of various pigments of which the acetate of 
lead is the base {e.g.. lead chromates). Among tvpe-founders 
the symptoms of lead poisoning are not very rare, and even 



234 TEXT-BOOK OF HYGIENE. 

compositors sometimes suffer from lead poisoning. In the latter 
case the lead must be absorbed through the skin in order to 
produce its effects. 

The various forms in which lead poisoning affects the indi- 
vidual are the lead cachexia, manifested by loss of weight, dis- 
coloration of the skin, the characteristic blue line along the 
gums, diminution of the salivary secretion, a sweetish taste, and 
offensive odor of the breath ; then lead colic, the features of 
which are well known ; lead paralysis, the characteristic " wrist- 
drop," which requires prompt and intelligent treatment, other- 
wise permanent atrophy of the affected muscles often takes place. 
Among other nervous manifestations of the poison is a painful 
affection of the lower extremities, attacking joints and flexor 
muscles, and remittent in character. At times anaesthesia of the 
skin of the head and neck is present. In rare cases serious 
mental derangement occurs. Other grave nervous lesions, such 
as the so-called saturnine hemiplegia and tabes, are happily 
extremely rare among the workmen in the metal at the present 
day. 

Mercurial poisoning is frequent among the artisans who 
work in the metal. The smelters of the ore suffer severely and 
in a large proportion of the entire number employed. Their 
average age at death is 45 years. Mirror-makers suffer most 
severely of all the artisans who come in contact with the vapors 
of the metal. It is beyond question that the confinement in 
badly-ventilated work-rooms is largely responsible for the poi- 
sonous effects of the metal upon this class. The special forms 
in which the poisonous effects are manifested in mirror-makers 
are salivation, mercurial tremor, and nervous erethism, but, in 
addition, a very large proportion suffer from pulmonary con- 
sumption. It is stated that 71 per cent, of the total deaths 
among mirror-makers (those who coat the glass with the mer- 
curial alloy) are from phthisis. 

Among women the symptoms are aggravated, and abortion 
frequently occurs. Of the children of women suffering from 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 235 

mercurial poisoning born living at term, 65 per cent, die within 
the first year. 

In the Almaden quicksilver mines in Spain a considerable 
proportion of the workmen suffer from the milder symptoms of 
mercurial intoxication (gingivitis, salivation, or dryness of the 
mouth). The more severe manifestations (tremor, convulsions, 
contractures, violent muscular pains, paralysis, cachexia) are 
much less frequent, and latterly not so severe as they were 
formerly. 

Fire-gilders, fulminate- makers, and physical instrument- 
makers not infrequently suffer from the deleterious effects of 
inhaling the vapor of mercury. Hatters are also liable, to a 
considerable extent, to the poisonous effects of the metal. 1 

It has been found that upon sprinkling the floor of the 
work-room of mirror-makers with aqua ammonia, so as to im- 
pregnate the atmosphere with ammonia, the bad effects of mer- 
cury on the system are markedly diminished. Care must be 
taken, however, not to use the ammonia to excess, otherwise the 
diseases caused by this agent may attack the workmen. 

Zinc or copper vapors, or possibly a combination of the 
two, given off from the brass, which is an alloy of these metals, 
produces a peculiar train of symptoms known as " brass- 
founders' ague." The symptoms are described by Hirt, who 
has suffered from two attacks of the affection himself, as fol- 
lows ~ : "A few hours after attending the process of brass- 
casting, one notices a peculiar, uncomfortable sensation over the 
whole body. More or less severe pains in the back and gen- 
eral lassitude cause a discontinuance of the ordinary occupa- 
tion. While the pains appear now here, now there, and are 
extremely annoying, no changes in the pulse or respiration are 
noticeable. In a short time, however, usually after the patient 
has taken to the bed, chilliness comes on, which soon increases 
to a decided rigor, lasting fifteen minutes or longer. In the 

i Hatting as Affecting the Health of Operatives, L. Dennis, Report New Jersey State 
Board of Health, 1879 ; Connecticut State Board of Health, 1883. 
3 Op. cit., p. 122. 



236 TEXT-BOOK OF HYGIENE. 

course of an hour or less the pulse now reaches a rapidity of 
100 to 120 beats per minute. A tormenting cough, combined 
with a feeling of soreness in the chest, comes on. In conse- 
quence of the repeated acts of coughing, the increasing frontal 
headache produces exceeding discomfort. Soon, however, usu- 
ally after a few hours, the height of the attack is reached ; free 
perspiration indicates the stage of defervescence, and during the 
gradual diminution of the symptoms the patient falls into a 
deep sleep, lasting several hours. On awakening, a slight 
headache and lassitude only remain as reminders of the 
attack." 

It is said that about 75 per cent, of the workmen in brass- 
foundries are attacked by this affection ; the attack is liable to 
be repeated at every exposure. 

A chronic form of poisoning is said to occur among zinc- 
smelters after following their occupation for ten to twelve years. 
It consists of hyperesthesia, formication, and burning of the 
skin of the lower extremities, soon followed by alteration in the 
temperature and tactile sensation, and diminution of the mus- 
cular sense. Paresis of the lower extremities sometimes comes 
on. The disease has not yet been sufficiently investigated. 

Aniline vapor is exceedingly poisonous when inhaled in a 
concentrated state. Hirt describes an acute form which usually 
results fatally: "The workman falls suddenly to the ground; 
the skin is cold, pale ; the face is cyanotic, the breath has the 
odor of aniline, the respiration is slowed, and the pulse increased. 
The sensation, diminished from the beginning of the attack, 
gradually entirely disappears, and death follows in a state of deep 
coma." 1 There is a milder form which comes on after several 
days of exposure. It is characterized by laryngeal irritation, 
diminution of appetite, headache, giddiness, great weakness, 
and depression. The pulse is rapid, small, and irregular. 
Respiration is little altered. There is decrease of sensibility of the 
skin. Convulsions may occur, but are usually of short duration. 

1 Op. cit., p. 127. 



DISEASES DUE TO INHALATION OF DUST. 237 

The chronic form of aniline poisoning is characterized by 
three sets of symptoms : those affecting the central nervous 
system, the digestive tract, and the skin. Among the first are 
lassitude, headache, roaring in the ears, and disturbances of 
sensation and motion of greater or less degree. 

The digestive derangements consist in eructations, nausea, 
and vomiting. 

The cutaneous lesions are eczematous or pustular eruptions, 
and sometimes round, sharply-circumscribed ulcers with callous 
borders. 

There is no trustworthy evidence that in the manufacture 
of aniline colors poisonous symptoms are produced in the 
workmen. 

II. — DISEASES DUE TO THE INHALATION OF IRRITATING OR 
POISONOUS DUST. 

The inhalation of air containing particles of organic or 
inorganic matter has long been accepted as a cause of certain 
special diseases of artisans. The diseases so caused are usually 
limited to the pulmonary organs, and consist of acute and 
chronic catarrh, emphysema of the lungs, pneumonia, interstitial 
inflammation of the lungs, — the so-called fibroid phthisis or pul- 
monary cirrhosis. 

Goal-dust is inhaled by coal-miners, charcoal-burners, coal- 
handlers, firemen, chimney-sweeps, foundry-men, lead-pencil 
makers, etc. Chronic bronchial catarrhs are most frequent, 
while phthisis and emphysema are almost absent from the list 
of diseases affecting these workmen. Dr. W. B. Canfield has 
reported an interesting case of pneumonoconiosis in which there 
was coincident bacillary phthisis. 1 The table on page 208 shows 
that the expectation of life of foundry-men, furnace-men, fire- 
men, and chimney-sweeps is much below the average. 

Metallic dust is inhaled by blacksmiths, nailers, cutlers, lock- 
smiths, file-cutters, cutlery- and needle- polishers, etc. While 

1 Trans. Med. and Chir. Fac, Md., 1889. 



238 TEXT-BOOK OF HYGIENE. 

in this class of workmen cases of bronchitis and pneumonia 
are relatively frequent, much the largest proportion suffer from 
phthisis. A table compiled by Hirt shows that out of the total 
number of sick in the different classes of workmen the cases of 

phthisis were : — 

62.2 per cent, for file-cutters, 
69.6 " " needle-polishers, 

40.4 " " grinders, 

12.2 " " nailers. 

The Massachusetts table gives the average duration of life 
for blacksmiths at 53.26 years, of nail-makers at 41.49 years, 
and of cutlers at 39.21 years. The needle-polishers at Sheffield, 
as already stated (page 210), have only an average duration of 
life of 30.66 years. In this work and that of grinding knives, 
scissors, and similar articles, the metallic dust is mixed with 
mineral dust (particles of silica from the grindstone). This 
mixture seems to be much more deleterious than metallic dust 
alone, as shown by the shorter average duration of life and the 
enormous percentage of cases of consumption. 

Mineral dust is inhaled by the workmen in a large number 
of different industries. The grinders in the ground-glass factories 
suffer most severely. Hirt found the average duration of life in 
grinders who began this occupation after their 25th year to be 
42.50 years, while in those who began at the age of 15 the 
average duration was 30 years. 

Millstone cutting is also a very dangerous occupation. Pea- 
cock 1 gives the average age of these workmen at 24.1 years. 
Stone-cutters generally suffer frequently from phthisis, probably 
largely in consequence of the constant inhalation of the mineral 
dust produced during their work. The Massachusetts table gives 
the average age at death of these workmen at 40.90 years, 
while Hirt's table gives a much lower age, namely 36.3 years. 
Potters and porcelain-makers are exposed to similar dangers 
from their occupation, but to a much less degree. The table on 

1 Quoted by Merkel, in von Pettenkofer und Ziemssen's Handbuch der Hygiene, II Th., 
4 Abth., p. 197. 



DISEASES DUE TO INHALATION OF DUST. 239 

page 208 gives the average age at death at 56.67 years, — rather 
a high average. 

Slaters and workmen in slate-quarries suffer in a large pro- 
portion of cases from chronic pneumonia, and die at a compara- 
tively early age. 

Masons and carpenters have an average duration of life of 
50.33 and 53.33 years, respectively. One-third of all the diseases 
from which they suffer affect the respiratory organs. 

Gussenbauer has reported a very interesting series of cases 
of a peculiar inflammatory affection of the diaphyses of the long 
bones in the artisans who are engaged in the manufacture of 
pearl buttons. 

Gem-finishers are exposed not only to the inhalation of 
dust, but to poisonous gases (carbon monoxide) and vapors 
(lead). The proportion of sickness among them is very high. 

Vegetable Dust. — The workmen compelled to inhale vege- 
table dust are those who work in tobacco, cotton-operatives, 
flax-dressers, paper-makers, weavers, wood-turners, millers, and 
laborers in grain-elevators. 

Workmen in tobacco usually suffer, within a few weeks 
after beginning work, from a nasal, conjunctival, and bronchial 
catarrh, which soon passes off, as the mucous membranes seem 
to become accustomed to the irritation. Nausea is also frequent 
at first, due probably to the absorption of small quantities of 
nicotine. Females exposed to tobacco-dust usually suffer from 
digestive and nervous troubles. They are also said to abort 
frequently. 

Dr. R. S. Tracy, 1 as a result of his observations among 
cigar-makers in New York, states that the fecundity of these 
people is much less than the average. Three hundred and 
twenty-five families visited had only 465 children, an average 
of 1.43 to each family. Dr. Tracy is inclined to attribute this 
to the frequent abortions that occur among the females exposed to 
the inhalation of tobacco-dust. According to the Massachusetts 

1 Buck's Hygiene and Public Health, vol. ii, p. 62. 



240 TEXT-BOOK OF HYGIENE. 

table, cigar-making is an unfavorable occupation, the average 
age at death being 38.36 years. 

Cotton-operatives, flax-dressers, weavers, and workmen in 
paper-mills are subject to various diseases of the respiratory 
organs. Coetsem, as long ago as 1836, described a peculiar 
pulmonary affection among cotton-operatives, which he termed 
pneumonie cotonneuse. The observation does not seem to have 
been verified by others ; at all events, the author is unable to 
find any other record of a similar affection in the literature of 
the subject. Among weavers the mortality from phthisis is 
comparatively high. Among paper-makers Hirt found an 
average duration of life of 37.6 years. The people who sort 
rags are liable to a fatal infectious disease, "rag-sorters' disease" 
(Hadernkrankheit 1 ), which resembles in all respects, and is prob- 
ably nothing less than, anthrax. No cases have been reported 
in this country, but, as the importation of rags from abroad is 
carried on to a considerable extent, no apology is believed to be 
necessary for calling attention to it. The " wool-sorters' disease," 
to which attention has recently been called in England, is doubt- 
less similar in its nature. 

Millers suffer in a large proportion of cases from pulmonary 
affections, especially bronchial catarrh and pneumonia. Accord- 
ing to Hirt, 20.3 per cent, of all the diseases of these workmen 
are pneumonias, 9.3 per cent, bronchial catarrhs, 10.9 per cent, 
phthisis, and 1.9 per cent, emphysema. The average duration 
of life is 45.1 years. The Massachusetts table gives 57.14 years, 
— a very much more favorable exhibit. 

The laborers in grain-elevators are compelled to inhale a 
very irritating dust, which causes acute and chronic catarrhs of 
the respiratory organs. Dr. T. B. Evans, of Baltimore, has 
reported a series of cases of catarrhal pneumonia in these work- 
men, which were characterized by some very peculiar features. 
Brush-making, according to the statistics of Hirt, is a very dan- 
gerous occupation. Nearly one-half of the deaths among brush- 

1 See article by Soyka, Realencyclopaedie d. ges. Heilk, Bd. VI, p. 165. 



DISEASES DUE TO POISONOUS SUBSTANCES. 241 

makers are from phthisis, due, in great measure, to the inhalation 
of the sharp fragments of bristles produced in trimming the 
brushes. In the Massachusetts table the average duration of 
life is given at 43.11 years. 

III. DISEASES DUE TO THE ABSORPTION OR LOCAL ACTION OF 

IRRITATING OR POISONOUS SUBSTANCES. 

Arsenic is used in the manufacture of green pigments and 
for various other purposes in the arts. In the preservation of 
furs and in taxidermy it finds extensive use. In the prepara- 
tion of the pigment known as Paris green the workmen are 
frequently entirely covered by a layer of the poisonous salt. The 
poisonous symptoms occur in consequence of the absorption of 
the poison through the skin or from its local action, and but 
rarely on account of inhalation of vapors or dust in which it is 
contained. The most marked symptoms are chronic gastric 
catarrh, superficial erosions in the mouth, dry tongue, thirst, and 
a burning sensation in the throat. These symptoms may con- 
tinue for months, or even years, and gradually produce a com- 
plete breaking down of nutrition and the vital powers. Violent 
itching skin eruptions of an eczematous character are not infre- 
quent complications of the internal symptoms. 

Lewin has described a localized pigmentation of the skin 
in workmen (engravers) in silver. The left hand is especially 
affected. The occurrence of the affection is explained by the 
numerous slight injuries of the hands by the graver's tools and 
the local absorption and decomposition of the silver. 

Phosphorus produces two classes of effects in persons sub- 
jected to its influence. The milder effects are produced by the 
inhalation of the fumes of the substance, and are limited to 
digestive disturbances and diseases of the pulmonary organs. 
The severer symptoms are only observed among the employes 
in match-factories, and are due to the local action of the phos- 
phorus upon the tissues affected. 

The characteristic disease produced by phosphorus is a 

16 



242 TEXT-BOOK OF HYGIENE. 

painful periostitis of the lower or upper jaw. The limitation 
of the affection to this locality is believed to be due to the action 
of the phosphorus dissolved in the saliva. The fact that the 
lower jaw, with which the saliva comes more thoroughly in 
contact, is most frequently affected seems to indicate that this 
view is the correct one. The disease begins, on an average, five 
years after the beginning of the employment. Hirt estimates 
the proportion of employes in match-factories attacked at 11 to 
12 per cent. The first symptom of the disease is toothache, 
soon extending to the jaw. The cervical glands swell up ; the 
gums become reddened and spongy ; abscesses form about the 
diseased teeth, from which large quantities of thin, offensive pus 
are discharged. Examination with a sound reveals carious, 
nodulated bone. The cheeks become swollen, erysipelatous, 
and may suppurate and discharge pus externally. 

Hutchinson has reported a case in which the long-continued 
internal administration of phosphorus as a medicine produced 
maxillary necrosis. 

The destruction of the soft tissues continues until resection 
of the jaw is finally undertaken and the disease checked by 
surgical interference, and removal of the patient from the influ- 
ence of the pernicious substance. 

Dr. J. Ewing Mears reports 1 16 cases of phosphorus ne- 
crosis. He concludes " that the antidotal powers of turpentine 
have been established, both in neutralizing the effects of the 
poison upon operatives during their work and also in the treat- 
ment of the early stage of the disease. The disease is to be 
prevented by the adoption of thorough methods of ventilation, 
stringent rules with regard to cleanliness, and the free disen- 
gagement of the vapors of turpentine in all the apartments of 
factories in which the fumes of phosphorus escape." 

In the manufacture of quinine a troublesome eczema is 
caused in about 90 per cent, of the employes. It seems to be 
due to emanations given off from the boiling solutions. It 

1 Trans. Am. Surg. Association, 1887. 



DISEASES DUE TO ELEVATED OR VARIABLE TEMPERATURE. 243 

begins with intense itching, followed by swelling and the forma- 
tion of vesicles, which soon burst and form crusts. There is 
considerable fever when the swelling is great. It is said that 
blondes are more frequently affected than those of dark com- 
plexion. The disease soon disappears if the work is given up. 

The workmen engaged in the manufacture of bichromate 
of potassium are said to suffer from an ulceration of the nasal 
mucous membrane very similar to that already described as due 
to the vapors of hydrochloric acid (p. 212). Rapidly spreading, 
deep ulcers are also said to form if the bichromate comes in 
contact with abraded surfaces of the skin. 

The strong alkali handled by tanners frequently produces 
fissured eczemas of the hands, which are painful and often diffi- 
cult to cure. 

The workmen in petroleum refineries frequently suffer from 
acneiform or furuncular eruptions. 

Among glassrblowers, syphilis is frequently communicated 
by an infected mouth- piece which is used by the men in turn. 

IV. DISEASES DUE TO EXPOSURE TO ELEVATED OR VARIABLE 

TEMPERATURE OR ATMOSPHERIC PRESSURE. 

Cooks and bakers are exposed almost constantly to a high 
temperature, which produces an unfavorable influence upon 
health and predisposes them to diseases of various kinds. The 
Massachusetts table shows that cooks have a much shorter 
duration of life than bakers, although the statistics of both 
trades are unfavorable. 

The prevailing diseases among cooks and bakers are rheu- 
matism and eczematous eruptions, generally confined to the 
hands, forearms, and face. 

Blacksmiths, founders, and firemen suffer from the intense 
heat to which they are exposed, in addition to the inhalation of 
coal-dust, as has already been pointed out. The stokers in the 
engine-rooms of steam-ships suffer especially from the excessively 
high temperature to which they are subjected by their occupation. 



244 TEXT-BOOK OF HYGIENE. 

A form of heart-weakness, described by Levick as " fireman's 
heart," is prevalent among them. 

Sailors, farmers, coachmen, car-drivers, and teamsters are 
subjected to stress of weather, changes of temperature, and 
storms. They suffer frequently from rheumatism, acute bron- 
chitis, pneumonia, and Blight's disease. Car-drivers are said 
also to suffer from painful swelling of the feet, varicose veins 
and ulcers, and mild spinal troubles. 1 

Sun-stroke is not confined to any class of artisans, but 
persons who perform very hard labor, especially in a confined 
atmosphere, suffer most frequently. 

The effects of compressed air on workmen in tunnels and 
deep mines has already been referred to. 2 The most serious 
symptoms occur not when the individual is subjected to the 
increased pressure, but when the pressure is too rapidly dimin- 
ished. 

V. DISEASES DUE TO THE EXCESSIVE USE OF CERTAIN ORGANS. 

The prevalent belief that the overuse of the intellectual 
faculties is a frequent cause of mental disease is not borne out 
by facts. Men and women who perform an amount of mental 
work regarded by most persons as excessive have, in spite of 
this, a long duration of life. There are no exact statistics upon 
this subject, but Caspar, half a century ago, made the following 
estimate of the average duration of life among professional men : 
Clergymen live 65; merchants, 62.4 ; officials, 61.7 ; lawyers, 
58.9 ; teachers, 56.9, and physicians, 56.8 years. In the table 
on page 209 the figures are somewhat less favorable, although 
corresponding in general with those of Caspar. Hence, it is 
seen that, of professional men, those whose occupation compels 
the exercise of high mental powers have a higher duration of 
life than any other class, except farmers and mechanics engaged 
actively out of doors. Those professional occupations only 
which necessitate a more or less irregular mode of life and 

1 A. McL. Hamilton in Report New York Board of Health, p. 444, 1873. 
a Chapter I, p. 12. 



DISEASES DUE TO A SEDENTARY LIFE. 245 

frequent subjection to physical exhaustion and dangers from 
contagious disease, such as the work of physicians and journal- 
ists, make an unfavorable showing in the statistics. The prop- 
osition may be laid down that it is not mental activity, however 
great, but mental worry that tends to the abbreviation of life. 

The occupation of a tea-taster is said to produce a peculiar 
nervous condition, manifested in muscular tremblings, etc., 
which compels the individual to give up the work in a few years. 

Persons who test the quality of tobacco, an occupation corre- 
sponding to that of tea- taster, are said to suffer from nervous symp- 
toms, which may include amaurosis and other grave affections. 

Those persons who are compelled to use their eyes con- 
stantly upon minute objects frequently suffer from defective 
vision. So engravers, watch-makers, and seamstresses are liable 
to near-sightedness, amaurosis, and irritation of the conjunctiva. 
Public speakers and singers frequently suffer from catarrhal or 
even paretic conditions of the throat, which usually disappear 
on relinquishing the occupation for a time. 

Telegraph operators and copyists suffer from a peculiar 
convulsive affection of the fingers, called "writers' cramp." 
Cigar-makers are also said to suffer from a similar cramp of 
the fingers used in rolling cigars. Performers on wind instru- 
ments are liable to pulmonary emphysema, on account of the 
pressure to which the lungs are frequently subjected. Boiler- 
makers often suffer from deafness, in consequence of their 
constant existence in an atmosphere in a state of continual violent 
vibration. The affection is generally recognized as "boiler- 
makers' deafness." Dr. C. S. Turnbull has reported several 
cases of " mill-operatives' deafness." Its characteristic is an 
inability to hear distinctly except during a noise. 

VI. DISEASES DUE TO A CONSTRAINED ATTITUDE AND 

SEDENTARY LIFE. 

It is probable that the large mortality and morbility rate 
of persons whose occupations keep them confined within doors 



246 TEXT-BOOK OF HYGIENE. 

are due, next to the defective ventilation, to the constrained 
attitude which most of them necessarily assume. Thus, carvers, 
book-binders, engravers, jewelers, printers, shoe-makers, book- 
keepers, and cigar-makers all have a low average duration of 
life. It is found, likewise, that many of these artisans suffer 
most from pulmonary and digestive troubles, among the former 
being phthisis, and among the latter constipation, dyspepsia, and 
haemorrhoids. 

VII. — DISEASES FROM EXPOSURE TO MECHANICAL VIOLENCE. 

It will be seen, by reference to the table on page 209, that 
all persons whose occupations involve an intimate contact with 
machinery, and in the pursuit of which accidents frequently 
happen, have a short duration of life. Persons liable to these 
dangers are machinists, operatives in factories, workmen in 
powder-mills, baggage-masters, brakemen, drivers, engineers, 
firemen, and other workmen on railroads. Aside from the 
diseases to which some of these classes are liable in consequence 
of exposure to variable atmospheric conditions, the grave acci- 
dents to which they are so frequently exposed render their 
occupations extremely dangerous. Brakemen on freight rail- 
roads, for example, are classed by insurance companies as the 
most hazardous " risks," and some companies refuse to take them 
at all. The table on page 209 tends to confirm the conclusion of 
the insurance companies, for, excluding the class of " students," 
which, for manifest reasons, cannot be used as a comparison, 
brakemen have the shortest average duration of life of all the 
occupations noted in the table. 

[The student is referred, for more complete information on 
the subjects considered in the foregoing chapter, to the following 
works : — 

L. Hirt, Die Kranklieiten der Arbeiter. — Enlenburg, Handbuch der 
Gtewerbehygiene. — Layet, Hygiene des Professions et des Industries. — 
Arlidge, The Diseases of Occupations.] 



QUESTIONS TO CHAPTER IX. 

Industrial Hygiene. 

How may various occupations induce disease? Are such diseases 
always necessarily due to the occupations, or are there incidental factors 
that might be avoided ? What classes of men have the greatest expecta- 
tion of life ? What occupations are especially unfavorable to health ? 
What diseases do they usually produce ? How may diseases of occupa- 
tions be conveniently classified ? 

What disorders are liable to be produced by the inhalation of the 
gases of the mineral acids ? What peculiar symptoms may be due to 
the constant inhalation of the fumes of hydrochloric acid? What effect 
has ammonia gas? What disease is frequently due to the constant 
inhalation of chlorine gas? What other disease is also especially 
favored by it ? What are some of the symptoms produced by the gas 
in a concentrated state ? By the constant inhalation of the gas ? 

In what occupations is carbon monoxide often given off to the air? 
What are some of the acute symptoms produced by it ? What of the 
chronic poisoning by the gas ? Is there any evidence that carbon diox- 
ide in small amounts may cause symptoms of chronic poisoning? What 
are some of the manifestations in cases of acute poisoning by this gas ? 
What other gas is often found in mines, and how may it be dangerous to 
life ? How may its dangers be avoided ? 

Where may sulphuretted hydrogen be found in quantities sufficient 
to produce serious results? What are some of the evil effects due to the 
inhalation of the vapor of bisulphide of carbon? Of iodine and bro- 
mine? Of turpentine? Of petroleum? 

In what occupations are the laborers subject to lead poisoning? 
What effect has it on the duration of life? In what forms may lead 
poisoning manifest itself? What proportion of workers in lead are 
affected by it? 

What proportion of workers in mercury are affected by that metal ? 
To what disease are mirror-makers especially prone ? What are some 
of the symptoms of mercurial intoxication ? What peculiar effect has 
the metal upon female laborers and their children ? How may the bad 
effects of mercury be diminished ? 

What are the symptoms of" brass-founders' ague"? Is it common 
among the class indicated ? What symptoms may indicate chronic zinc 
poisoning ? 

What are the symptoms of acute poisoning by aniline vapor ? What 
peculiarities characterize chronic aniline poisoning? Are these or others 
liable to be produced in those employed in the manufacture of aniline 
colors ? 

(247) 



248 QUESTIONS TO CHAPTER IX. 

What class of diseases is especially apt to be caused by the con- 
tinued inhalation of dust ? What is the most common affection among 
those who inhale coal-dust in large quantities? From what pulmonary 
disease are they exceptionally free? Is the expectation of life among 
this class of workmen high? What diseases seem to be especially 
favored b}' the inhalation of metallic dust? Which of these is the most 
frequent ? What is the effect of a mixture of metallic and mineral 
dust? What occupations have a high morbidity and mortality from 
phthisis? What from chronic pneumonia or other pulmonary affections ? 
To what peculiar affection are pearl-button-makers subject? 

What workmen habitualty inhale vegetable dust? What disturb- 
ances are due to the inhalation of tobacco-dust? What effect has it on 
fecundhVv, and wiry ? 

To what diseases are workers in cotton and flax subject, and from 
which one especially is the mortality high ? What is the average dura- 
tion of life among paper-makers ? To what disease are rag- and wool- 
sorters liable ? From what affections do millers and workers in grain- 
elevators suffer? Why is the mortality from phthisis so high among 
brush-makers ? 

What substances are liable to cause disease by absorption or local 
action? What are some of the symptoms common to those working 
with arsenic ? What two classes of effects are observed among those 
exposed to phosphorus vapors? To what is each class due? What 
may be used as a preventive and antidote to such cases of phosphorus 
poisoning? What malady is associated with the manufacture of qui- 
nine ? What other substances ma}* - produce eczema or ulceration in their 
preparation or manufacture? 

What diseases are favored by continued exposure to high tempera- 
tures ? In what occupations are such disturbances accordingly prevalent ? 
What class of laborers are subject to sudden changes or to extremes of 
temperature? What are some of the maladies that may be, in part, 
traced to such causes? What are the effects of compressed air upon 
laborers in it, and when are they manifested ? 

What diseases or disturbances may be due to the excessive use of 
certain organs ? Is there any evidence that excessive mental activity 
leads to mental disease? What is a factor in the production of the 
latter? Wh}- is the mortality-rate so high among those who follow 
sedentary or in-door occupations ? What disturbances are most common 
to these pursuits ? In what occupations are the laborers especially liable 
to mechanical violence ? Is the average duration of life of such work- 
men low or high ? 



CHAPTER X. 

Military and Camp Hygiene. 

The subjects embraced in this chapter can be most con- 
veniently arranged under the following heads : — 

I. The Soldier and his Training. IV. The Dwelling of the Soldier. 

II. The Food of the Soldier. V. Camp Diseases. 

III. The Clothing of the Soldier. VI. Civilian Camps. 

I. THE SOLDIER AND HIS TRAINING. 

The relations existing among different nations at the present 
time require that a standing army of greater or less number be 
maintained by each for the common safety. This being the 
case, it needs no argument to prove that such an army should 
be composed of the best material available in order that it may 
be depended upon for defense or offense when necessity demands 
that it should be called into active service. 

Hammond says with truth 1 that " a weak, malformed, or 
sickly soldier is not only useless but a positive incumbrance " to 
an army. It is of the first importance, therefore, to exclude 
from the military service, by a rigorous physical examination, all 
individuals whose physical condition is defective, who are either 
suffering from or predisposed to disease. 

The foremost authorities on military hygiene are agreed 
that no recruit should be enlisted for actual service before the 
20th year. In the English army the lowest age at present is 
19 years ; in Germany, 20 years ; in France, 20 years for actual 
service (recrues), 18 years for enlistment (engages); and in the 
United States, 21 years. The limit of age upward in the latter 
army is 45 years, except in cases of re-enlistments. The height 
of recruits must be at least 165 centimetres; minimum chest 

1 Hygiene, p. 19. Philadelphia, 1863. 

(249) 



250 TEXT-BOOK OF HYGIENE. 

measurement 75 centimetres, with at least 5 centimetres' expan- 
sion ; and weight from 54 to 81 kilogrammes. In the cavalry 
service the maximum weight is 75 kilogrammes. Every recruit 
must be vaccinated before enlistment. 

The physical examination of recruits before enlistment 
must be made by a medical officer, whose decision, in the United 
States army, is definitive. In the German army the decision of 
the medical officer is not final, but subject to revision by the 
recruiting officer, who may, if he sees fit, overrule the medical 
officer's opinion and enlist a man who has been decided to be 
unqualified for the military service. In this and various other 
respects, such as pay, rank, and effective power, the Medical 
Staff of the United States Army has many advantages over that 
of most foreign armies. 

II. — THE FOOD OF THE SOLDIER. 

The army ration of the United States, which is given below, 
was fixed by regulations before the more-recent researches of 
Professor Voit on nutrition were completed. The ultimate com- 
position, which yields 142 grammes proteids, 116 grammes fats, 
and 435 grammes carbohydrates, shows an excess of fats and 
deficiency of carbohydrates. Table XXI shows the daily allow- 
ance for each soldier : — 

Table XXI. 
342 grammes pork or bacon, or 



567 


u 


fresh beef. 


454 


a 


hard bread, or 


566 


u 


flour. 


68 


u 


beans or peas, or 


45 


u 


rice or hominy. 


45 


u 


green coffee. 


17 


u 


salt. 


68 


u 


sugar. 



To this is also added vinegar, pepper, and tea in place of 
coffee. Although the regular food-allowance in the United States 
army is liberal, and is largely in excess of the needs of the soldier 



THE CLOTHING OF THE SOLDIER. 251 

in garrison, medical officers generally agree that in active service 
it is insufficient in quantity and not sufficiently varied. 

The money value of each of the above articles in the ration 
is fixed by the government, and may be drawn instead of certain 
of the articles, and other articles of food purchased and thus 
the dietary varied. The money so drawn constitutes what is 
known as the " company fund." In the hands of a judicious 
commanding officer, the company fund can be made a source 
of great benefit and comfort to the men, but that it is at 
times mismanaged or misapplied is well known to army sur- 
geons. 

Aside from the insufficient quantity and variety of food 
furnished to soldiers, the cooking, especially in temporary camps, 
is often defective and causes digestive derangements and con- 
sequent innutrition. A good cook should be attached to every 
company. 

III. — THE CLOTHING OF THE SOLDIER. 

The clothing of the United States soldier is tolerably well 
adapted to its uses. It is generally well made, and of good, 
serviceable material. The only exception that can be made with 
reason is that the foot-gear is not made to individual measure, 
and hence peculiarities of shape of the feet cannot be taken 
account of. For this reason painful affections of the feet, due to 
ill-fitting boots or shoes, are of frequent occurrence. 

When on a march, the soldier carries his extra clothing 
packed in a knapsack and strapped upon the back. His 
blankets and great-coat are rolled into a cylinder and strapped 
upon the knapsack. The weight each soldier has thus to carry, 
in addition to his arms and ammunition, amounts to considerable. 
There is reason to believe that the pressure produced by the 
straps of a heavy knapsack may cause not only discomfort but 
actual disease. It is believed by many officers that the knapsack 
could be abolished with advantage, and the extra clothing rolled 
up in the blanket, or a water-proof sheet, and slung over the 
left shoulder. 



252 TEXT-BOOK OF HYGIENE. 

IV. — THE DWELLING OF THE SOLDIER. 

Soldiers are generally housed either in barracks, huts, or 
tents. The former are usually the habitation of the soldiers 
in garrisons or permanent camps, while huts or tents are 
used for the purpose of sheltering the occupants of temporary 
camps. 

Barracks. — A military barrack is a one-storied building 
constructed of stone, wood, or iron, or a combination of these 
materials. The general plan of the barrack comprises a large 
room for the beds of the soldiers, one or more smaller rooms 
for the non-commissioned officers of the company or squad, and 
a wash-room. The sleeping-room of the soldier is also his living- 
or day- room. It is evident, therefore, that sufficient air-space 
and good ventilation must be provided if the soldier's health is to 
be maintained. In England, 17 cubic metres are recommended 
for the initial air-space. In the new barracks constructed in 
France according to the plans of M. Toilet, 22 cubic metres are 
allowed to each occupant. 

The special points of distinction of the system of Toilet, of 
which Schuster says that "to it belongs the future of barrack 
construction," are : The frame of the building is of light-iron 
ribs ; the interspaces are walled up with bricks or stone ; the 
roof is slate ; the ceiling is arched, and all corners are rounded to 
prevent lodgment of dust. Ventilation is provided by openings 
in the walls at the edge of the roof for the entrance of fresh air, 
and by ridge ventilators. 

In France, barracks have been built according to Toilet's 
system at Bourges, Cosne, Macon, and Autun. Although occu- 
pied but a short time, it appears that the health of the soldiers 
remains better in them than in the barracks constructed on the 
old style. The system would seem also especially to lend itself 
to the construction of hospitals. The wash- and bath- rooms of 
the barracks should be so arranged as to encourage the soldier 
to cleanliness. Where the only lavatory in a barrack is, as 
the author has seen it, an open porch, men are not likely to 



THE DWELLING OF THE SOLDIER. 253 

spend much time in cold weather in washing their faces and 
hands, to say nothing of the rest of their bodies. 

The kitchen and dining-room should be detached from the 
building serving as quarters ; otherwise the odors of the cooking 
will pervade the building. 

The sinks or latrines should be placed at some distance from 
the quarters and kitchen, and out of the line of prevailing winds. 
The writer has personal knowledge of a permanent military post 
within a few miles of the city of Washington, where, only a few 
years ago (and, for aught known to the contrary, at the present 
day), " the rear," or place of depositing excrement, was about 
70 metres distant from the kitchen and men's quarters, and 
directly in line with the prevailing winds ! 

Before erecting any buildings it is, of course, necessary to 
endeavor to secure a clean and dry subsoil. Attention is called to 
the principles underlying the construction of dwellings, Chap. VI. 

Tents and Huts. — The tents used in the army are the hos- 
pital-tent, the officers' wall- tent, the A -tent, and the shelter- 
tent, which is a modification of the last. The conical, or Sibley 
tent, which was frequently seen in camps in the early part of 
the war between the States, has gone out of use. Soldiers give 
the preference to the shelter tent, which is light, each man's 
piece weighing only 1.18 kilogrammes. Two pieces being 
joined together by buttons and button-holes, and thrown over a 
ridge-pole supported upon uprights, and the four corners fast- 
ened to pegs driven into the ground, form a tent 1.20 metres 
high, 1.65 metres long, and having a spread at the base of 
between 1.8 and 2.1 metres. Such a tent will form a comfort- 
able shelter for two men, unless there should be strong winds or 
driving rains, when the ends could be closed by blankets, brush, 
or an extra piece of shelter- tent. The uprights and ridge are 
steadied by short guy-ropes, one of which is furnished with 
each piece of the tent. 

In winter, especially when camps of more or less perma- 
nence are formed, the soldiers usually build log huts. The 



254 



TEXT-BOOK OF HYGIENE. 



interstices between the logs are plastered up with mud or clay, 
and the roof is formed of canvas, generally several pieces of 
shelter tent joined together. 

The ground around the tent or hut should be trenched in 
order to carry off the rain-fall. 

Cleanliness within and around tents or huts is of the first 
importance, and should be enforced in all camps by the proper au- 
thority. Military authorities have long since learned that in the 
matter of cleanliness of body, clothing, or surroundings voluntary 
action on the part of the soldier cannot be relied upon. Frequent 
and thorough inspections will alone secure proper cleanliness. 



V. CAMP DISEASES. 

The soldier's profession has been aptly characterized by 
Ruskin as " the trade of being slain." In the late war between 
the States, the total deaths of the Federal army numbered 359,496, 
— over 15 per cent, of the entire number of enlistments. Of this 
number, however, 224,586 (nearly two-thirds) died from disease, 
while the remaining 134,910 (a small fraction over one-third) were 
killed in battle or died from the effects of wounds. The colored 
troops especially suffered greatly from the effects of disease. 

Diarrhoea and Dysentery. — The most fatal diseases of camp 

life, especially in time of war, are diarrhoea and dysentery. The 

statistics of the Federal army during the late war are given in 

the following table 1 : — 

Table XXII. 

Total Deaths from Diarrhoea and Dysentery in the TJ. S. Army, from May 1, 1861, 

to June 30, 1866. 





White Troops, from 

May 1, 1861, to June 

30, 1866. 


Colored Troops, 
from July 1, 1863, 
to June 30, 1866. 


TotaL 


Acute Diarrhoea .... 
Chronic Diarrhcea . . . 
Acute Dysentery .... 
Chronic Dysentery . . . 


Cases. 
1,155,226 

170,488 

233,812 

25,670 


Deaths. 
2,923 

27,558 
4,084 
3,229 


Cases. 

113,801 

12,098 

25,259 

2,781 


Deaths 
1,368 
3,278 
1,492 
626 


Cases. 

1,269,027 

182,586 

259,071 

28,451 


Deaths 
4,291 

30,836 
5,576 
3,855 


Total 


1,585,196 


37,794 


153,939 


6,764 


1,739,135 


44,558 



1 Medical and Surgical History of the War, second medical volume, p. 2. 



CAMP DISEASES. 255 

Owing to the fact that a considerable number of deaths 
were reported without assigning any cause, Dr. Woodward esti- 
mates the total number of deaths from the above diseases at 
57,265, or, in the proportion of one death from diarrhoea and 
dysentery to three and one-half deaths from all diseases. Among 
the prisoners of war held by the Confederate States in Anderson- 
ville prison, where tolerably complete records were kept, more 
than half the total deaths were from diarrhoea and dysentery, 
while the ratio of deaths to cases of the above two diseases was a 
fraction over 76 per cent. This frightful mortality from these 
two diseases, both in the prisons and among the armies in the 
field, is principally due to the insanitary conditions surrounding 
the soldiers. Where the demands of hygiene were especially 
ignored ; where the food was bad in quality, or badly cooked ; 
the water impure ; the soil polluted by excreta and other filth ; 
where the men were exposed to stress of weather or to a paludal 
atmosphere; — under these conditions, the above diseases of the 
intestines prevailed in their greatest extent and most fatal 
degree. 

Malarial Fevers. — The diseases due to the paludal poison 
are exceedingly frequent among soldiers encamped in malarial 
sections. During the Civil War a very pernicious form of malarial 
fever received the designation of the locality in which it prevailed, 
and passed into the literature under the name of " Chickahominy 
fever." While malarial diseases were largely represented in the 
morbility reports during the war, the most serious results of the 
influence of the malarial poison were manifested in its effects 
upon patients sick with other diseases. Thus, typhoid fever, 
dysentery, or pneumonia, in a patient saturated with malaria, 
was very much more serious than where this complication was 
absent. In the malarial regions in the interior of the country, 
the Mississippi Valley, and the southern portion of the Western 
Territories, malarial fevers are among the most prevalent camp 
diseases. Greater attention in locating camps, and care devoted 
to draining the subsoil and maintaining a low level of the ground- 



256 TEXT-BOOK OF HYGIENE. 

water, would doubtless result in improvement in the sickness- 
rate from this cause in the army. 

Typlioid Fever. — Typhoid fever is prevalent in camps and 
garrisons. As it may be propagated through the medium of 
infected discharges of typhoid patients, it will readily be perceived 
that neglect of the precaution of promptly disinfecting such dis- 
charges will almost inevitably result in spreading the disease, 
either by direct inhalation of effluvia from the patient or excreta, 
of pollution of the drinking-water, or by contamination of the 
soil, and subsequently of the atmosphere, by the intestinal dis- 
charges of the patient. 

Phthisis. — Especially among troops in barracks phthisis is 
a very fatal disease. Formerly the mortality from it was very 
heavy. Recent improvements in the hygiene of military posts 
and greater care in selecting recruits have very greatly diminished 
the death-rate from phthisis among soldiers. Acute pulmonary 
affections, such as bronchitis, pleurisy, and pneumonia, are com- 
paratively frequent in camps, being due to exposure. 

Typhus Fever and Scurvy. — These two diseases are at the 
present day comparatively rare as camp diseases. They break 
out, however, on every occasion when the laws of hygiene are 
violated by permitting overcrowding, overwork, and underfeeding. 
This is almost certain to occur during war, and hence either 
fully-developed scurvy or a scorbutic taint are almost constant 
accompaniments of an army in the field. Among the allied armies 
in the Crimea, and in the Federal army during the war, scurvy 
and typhus fever claimed a considerable share in the mortality. 

Purulent Conjunctivitis. — This affection of the eyes is fre- 
quent among soldiers. It has even been supposed to be peculiar 
to soldier life, and has hence been termed " military ophthalmia." 
It is contagious, and is probably most often spread by the use 
of basins and towels in common. It is not merely annoying, 
but is a very grave affection, often causing perforation of the 
cornea and destruction of vision. The military surgeon should 
be on the lookout for it, and promptly isolate those infected. 



CAMP DISEASES. 257 

Venereal Diseases. — The contagious diseases of the sexual 
organs are a veritable scourge of the soldier's life. The history 
of these diseases is intimately interwoven with the history of 
armies, camps, and wars. The first wide-spread appearance 
of syphilis in the fifteenth century is coincident with the siege 
of Naples by the French army under Charles VIII. 1 It has 
since that time been a constant companion of the soldier in peace 
or war, and in all seasons and countries. Some progress toward 
its restriction has, however, been made in recent years in certain 
localities, but there is still wide room for improvement. 

In 1867 the venereal diseases reported in the Prussian army 
were 53.9 per 1000 of mean strength. In 1882 this number 
had been reduced to 41 per 1000, in 1883 to 36.4, and in 1884 
to 32.8 per 1000. In the Austrian army there were 81 pei 
1000 in 1870, diminishing to 73.5 per 1000 in 1884. In the 
British army the ravages of the venereal diseases were so terrible 
that legal measures for their restriction by subjecting prostitutes 
to inspection were taken. In 1859 the proportion of venereal 
disease among the home troops was 400 per 1000. In 1864 
and 1866 the passage and enforcement of the "Contagious Dis- 
eases Act " caused a marked diminution of these diseases. This 
reduction is particularly noticeable in syphilis. The following 
table gives a comparative view of the number of cases of syphilis 
per 1000 in the naval service at ports under the acts, and at 
ports where the acts were not enforced: — 

Table XXIII. 

Ports Under the Acts. Ports Not Under the Acts. 

1860-1863 (no restriction), 
1864-1865 (acts enforced), 
1866-1870 (acts extended), 
18U-1880, .... 

In the French army the proportion of venereal diseases was 
53 per 1000 from 1862 to 1866. In 1867 the proportion in- 
creased to 106 per 1000. This increase was attributed to the 

1 See article on Syphilis, Chapter XIX. 
17 



75.02 per 1000 


70.50 per 1000 


79.12 « " 


100.00 " " 


47.19 " " 


84.74 " " 


40.64 " " 


99.35 " " 



258 TEXT-BOOK OF HYGIENE. 

infection during the Mexican campaign. In 1879 the propor- 
tion had again diminished to 65.9 per 1000. 

In the United States Army the venereal diseases numbered 
63 per 1000 among the white and 81 per 1000 among the 
colored troops in 1884. A chart drawn by Major Charles 
Smart, surgeon United States army, 1 shows in an interesting 
manner how opportunity for infection influences the increase of 
venereal disease. At the breaking out of the war, when large 
numbers of men enlisted, the record shows a rapid increase of 
venereal. When the armies were in the field, and opportunities 
for the pursuit of Venus were few, the proportion of venereal 
decreased. At the expiration of the first triennial period of 
enlistment, the soldier with his final pay and thirty days' fur- 
lough crowded the cities, and entered on a period of dissipation 
which usually sent him back to the recruiting officer with empty 
pockets and an attack of gonorrhoea or syphilis. At this time 
the records show a large number of cases, which gradually 
diminished until the end of the war, when the opportunities 
for infection preliminary to the final muster-out crowded the 
hospitals once more with venereal cases. 

The experience with the Contagious Diseases Act in Eng- 
land points out the true way to limit or entirely extirpate this 
disease among the military and naval forces. An inspection at 
regular intervals not only of public prostitutes, but also of the 
soldiers themselves, and segregation of the infected in hospitals 
until the infective period is past, will do more to limit the 
spread of venereal disease than all other preventive measures, 
public or private, put together. 

VI. — CIVILIAN CAMPS. 

The camps of civil life, whether established for the purpose 
of furnishing a refuge to the inhabitants of cities invaded by 
epidemic diseases, as yellow fever or cholera, or whether for 
religious purposes (camp-meetings), or for recreation (hunting 

1 Medical and Surgical History of the War, third medical volume. 



CIVILIAN CAMPS. 259 

and fishing camps, etc.), should be organized and managed on the 
same principles as the military camp. The site should be selected 
with judgment — a clean, dry soil, and abundance of wood and 
water being requisite for a healthy camp. A superintendent 
or officer of the day should be appointed, whose duty it is to 
carefully inspect the camp daily, and compel the prompt removal 
of all filth and offal from the immediate vicinity. Cleanliness 
of person, clothing, and household is as important while 
" roughing it " in camp as at home. Singularly, this is very 
often forgotten by very intelligent people. 

The advantage of a well-administered refugee camp in case 
of yellow-fever epidemics has been clearly shown by the brilliant 
success of the depopulation of Memphis during the epidemic of 
1879 and of various Florida cities and towns in 1888. These 
experiments deserve imitation. 

[The following works on Military and Camp Hygiene 
should be studied in connection with this chapter : — 

Smart, The Hygiene of Camps, in Buck's Hygiene and Public 
Health, vol. ii. — Wolzendorff, Armee Krankheiten, in Realenc}-clop8edie 
d. ges. Heilk., Bd. I, p. 489. — Schuster, Kasernen, in von Pettenkofer 
und Ziemssen's Handbuch der Hygiene, II Th., 2 Abth. — Cameron: 
Camps, Depopulation of Memphis, Epidemics of 1878 and 1879. Public 
Health, vol. v, p. 152. — Frolich, Militarmedicin. — Medical and Surgical 
History of the War, especially the second and third medical volumes. 
— Annual Reports of the Supervising Surgeon-General of the United 
States Marine Hospital Service, 1888-9.] 



QUESTIONS TO CHAPTER X. 
Military and Camp Hygiene. 

What subjects may be considered under this head? Why should 
an army be composed of sound and healthy individuals ? Who should 
be excluded from an army or body of troops ? What is the lowest age 
at which recruits should be enlisted? What the highest age? What 
should be the minimum measurements of the recruit? Who should 
make the physical examination of the latter ? 

What can be said for the present army ration of the United States? 
In what is it excessive and in what deficient? In what other ways is it 
objectionable? What besides insufficient quantity and variety of food 
may cause digestive disturbances and innutrition in camp? 

What part of the United States soldier's clothing at present is most 
apt to cause physical discomfort? What change might be made to 
advantage in the manner of carrying the extra clothing ? How is it now 
carried ? 

What usually constitutes the dwelling of the soldier ? What is a 
military barrack, and what is its general plan ? What are the special 
points in favor of the Toilet system of barrack construction? What is 
to be said about the location of barrack lavatories, kitchens, and dining- 
rooms, sinks, and latrines ? On what kind of soil should barracks be 
located ? 

What sort of tents are used in the army ? What are the advantages 
of the simple shelter tent ? What may take the place of tents in winter ? 
What is of the first importance in all camps, and what is necessary to 
secure this ? 

In actual war what relation do the deaths from disease bear to those 
from injuries received in battle? What are the most fatal diseases of 
camp life ? AY hat are the causes leading to this fact ? What other class 
of diseases is especial^ apt to be frequent among soldiers ? What effect 
has the malarial poison on those sick with other diseases ? What would 
lessen the prevalence of malarial fevers in camp-life ? How may typhoid 
fever be propagated in camps and garrisons ? What respiratory diseases 
are common in camps, and to what are they due ? What two diseases, 
formerly common in camp-life, are now rare ? What affection of special 
sense is frequent among soldiers, and to what is this frequency to be 
attributed ? What contagious diseases are especially associated with 
the soldier? By what means may their spread be restricted? 

For what purposes may civilian camps be instituted ? What prin- 
ciples should be followed in organizing and maintaining them ? What 
are prime requisites ? Who should be in charge of such a camp ? Of 
what advantage may such camps be in case of epidemics of contagious 
diseases ? 

(260) 



CHAPTER XI. 

Marine Hygiene. 

The melancholy accounts of the mortality from scurvy., 
dysentery, and typhus fever, which were formerly a part of the 
history of so many naval and passenger vessels, are happily 
now only records of the past. Occasionally, however, careless- 
ness of the authorities, or of those responsible for the safety of 
people who " go down to the sea in ships," results in an out- 
break of one or other of these diseases even at the present day. 
Thus, for the fiscal year ending June 30, 1882, 71 cases of 
scurvy and purpura were reported by the medical officers of 
the Marine Hospital Service. It appears that only in one 
instance (where 6 cases of scurvy had occurred on one vessel) 
was any investigation ordered. A most superficial investigation 
showed that the law relating to the issue of lime-juice had been 
violated by the master of the vessel. No prosecution resulted. 
Such facts indicate that laxness in the enforcement of the regu- 
lations expressly made to prevent this fatal disease may be again 
followed by outbreaks of greater or less gravity. 

I. — THE SAILOR AND HIS HABITS. 

Although the sailor of the present day, especially in the 
naval service, is morally and intellectually far in advance of the 
" Jack Tar " of former days, his life, both afloat and on shore, 
leaves much to be desired on the score of temperance, chastity, 
and purity of thought and speech. The life of a sailor in the 
United States navy, thirty-eight years ago, is thus graphically 
described by Medical Director Albert L. Gihon 1 : " She was 
manned by a motley crew, of whom Americans were a minority, 

1 Thirty Years of Sanitary Progress in the Navy : Annual Address by the President to 
the Naval Medical Society, Washington, 1884. 

(261) 



262 TEXT-BOOK OF HYGIENE. 

and Englishmen, Irishmen, Northmen, and ' Dagos ' constituted 
the far greater part. Some had just returned from another cruise, 
having squandered or been robbed oi their three years' pay by 
the ' landsharks', who cajoled them, only half sober, to the ren- 
dezvous, to be reshipped, and thence to be herded, uncared for, 
on the receiving-ship, still popularly termed the ' guardo,' until 
drafted on board the first sea-going vessel. All of them were in 
debt, most of them insufficiently clad, and unable to properly 
outfit themselves. The wretched herd, who were thus gathered 
from the purlieus of Water Street, and North Street, and South 
Street, who at night were kenneled worse than dogs, by day 
fed like them, crouching on their haunches around greasy 
mess-cloths, cutting with jack-knives or pulling to pieces with 
grimy fingers the chunks of ' salt horse' and 'duff' which 
made their daily fare, and which, later in the cruise, were both 
spoiled and scanty, did not constitute an elevating subject for 
contemplation. 

" Stint of good food," continues Dr. Gihon, "was, however, 
not the chief of the old-time ' shell-back's ' ocean trials. Fed 
like a brute, housed worse than one, however faithfully his labors 
were performed, there was for him only a long, dreary season 
of imprisonment. For him there w r as no glad holiday on shore, 
when the land broke the monotony of the waste of waters. 
The officers might rush pell-mell out of the ship, but Jack could 
only strain his longing eyes upon the green fields or busy sea- 
ports. Notwithstanding the hardships of the voyage, the 
wretched food, and the outbreaks of disease, the crew were con- 
fined eight months on board ship, before ' general liberty ' was 
given, and then men and boys were sent on shore for forty-eight 
hours to indulge in a mad revel, and to return crazed by rum, 
battered, and bruised. The poor wretch, first made ravenously 
hungry for dissipation by his enforced confinement, was then 
expected to be temperate in the feast of indulgence offered him, 
and punished with vindictiveness if he sought to gorge himself 
with the poor semblance of pleasure. The 'cat' had been 



THE SAILOR AND HIS HABITS. 263 

abolished, but half a dozen boys strung upon the poop 'bucked 
and gagged ' ; half a dozen men triced up by their thumbs in 
the rigging ; each of the upright coffin-like ' sweat-boxes' with 
its semi-asphyxiated inmate ; the ' brig ' with its bruised and 
bloated crew in irons ; the main-hold with its contingent under 
hatches ; the sick-list swollen out of all proportions by in- 
ebriates, injured men, and venereal cases ; — these were the fruits 
of the ' general liberty,' which, within my professional life, 
represented the sum of sanitary interest in the man before the 
mast." 

Under such circumstances little could be hoped for in the 
way of personal advancement of the crew. The labors, how- 
ever, of the writer just quoted, and others, among whom may 
be mentioned Wilson and Turner, of the navy, and Woodworth, 
Hebersmith, and Wyman, of the Marine Hospital Service, have 
drawn prominent attention to the unsanitary conditions of the 
sailor's life, and legal enactments have done much to elevate 
him to his proper rank as a human being, entitled to be treated 
with humanity, at least. 

The seaman in the navy is now well clad, and receives an 
abundance of food, of good quality, usually well cooked and 
decently served. " Latrines and bath- and wash- rooms under 
the top-gallant forecastle ; mess-tables and benches ; mess- 
lockers and clothes-lockers ; a place where, and opportunities 
when, men can read and write ; and frequent daily liberty to 
go on shore, if not already common to every vessel, are yet now 
so generally the concomitants of the well-officered and well-dis- 
ciplined and efficient ship, that ere long their absence will be 
accounted a fault." 1 A medical corps, selected after the most 
rigorous examination known to the profession, and provided 
with every aid and appliance of medical science, cares for the 
enlisted sailor and marine when ill or injured, as tenderly as for 
the commissioned officer. 

The sailor in the merchant service, however, is still at the 

1 Thirty Years of Sanitary Progress in the Navy, Gihon. 



264 TEXT-BOOK OF HYGIENE. 

mercy of inhuman masters, who exact excessive service in return 
for insufficient food, scanty clothing, miserable lodging, abuse, 
ill-treatment, and neglect when sick or disabled. 

II. THE PASSENGER. 

During the ten years from 1870 to 1879, inclusive, passen- 
ger vessels carried 1,561,126 passengers from foreign ports en 
route to New York City. The mean duration of each voyage 
was 13.5 days. Out of the above number of passengers 2518 
died on the voyage, — a death-rate of 1.61 per 1000 for the 
voyage and 43.5 per 1000 per annum. These figures accentuate 
the importance of sanitary improvement in passenger vessels. 
The causes of this excessive mortality among emigrants — for it 
is almost exclusively among the passengers in the steerage, or 
" between decks," that the deaths occur — are overcrowding, im- 
proper feeding, defective ventilation, filthy personal habits, and 
inefficient medical attention when sick. Although overcrowd- 
ing is prohibited by statute, yet in every emigrant vessel that 
arrived in New York during the first nine months of 1880 the 
number of passengers was in excess of the number allowed by 
law. 1 The shorter voyages and better sanitary conditions ob- 
tainable since steamships, especially those built of iron, have 
come into general use for the carriage of passengers, have very 
much reduced the mortality on ocean voyages ; but, as just 
shown, the death-rate is still excessively high, and many more im- 
provements in the hygiene of emigrant vessels and of passengers 
are desirable. 

III. — THE SHIP AS A HABITATION. 

As a habitation for the sailor and passenger the ship de- 
mands the attention of the sanitarian. The principal points in 
which he is interested are the construction and ventilation of 
sleeping-apartments, and the means of keeping the entire ship 
clean and free of water and impure air. 

The keel is the foundation of the ship. Branching out 

1 Hygiene in Emigrant Ships, Turner, Public Health, vol. vi, p. 24. 



THE SHIP AS A HABITATION. 265 

transversely from it are curved timbers, the ribs, which, with the 
keel, constitute the ship's frame. The ribs are covered exter- 
nally and internally with planking, and the spaces between the 
two coverings are the frame-spaces, which are usually partly 
filled with filthy water, decomposing organic matter, and foul 
air. The water collects in the bottom of the vessel, the bilge, 1 
whence it is pumped out of the vessel. If the pumping is 
neglected the bilge-water becomes very offensive, and may cause 
disease in persons exposed to exhalations from it. The frame- 
spaces are rarely ventilated, and hence are frequent sources of 
pollution of air on board vessels. 

The sleeping-apartment of the crew of a merchant vessel 
is in the forecastle, usually a small, dark, damp, filthy, unven- 
tilated space in the bow of the vessel, where they are kenneled 
like brutes. On naval vessels the crews sleep on the berth- 
deck, which, in the rarest instances, is properly lighted and 
ventilated. The berth-deck is usually below the water-line. 
In nearly all and even the best class of vessels in the United 
States navy the air-allowance for each man is less than 3 cubic 
metres, rarely reaches 4, is oftener from 2 to 2^-, and is some- 
times as low as 1 cubic metre. The men swing by night in 
hammocks suspended from the beams overhead, and removed 
when not in use. carried on deck, and stored in lockers, called 
"hammock-nettings." on the ship's sides. 

That a ship should, above all, be seaworthy would seem to 
require no argument. It is self-evident that a leaky or rotten 
ship is at all times a highly dangerous habitation, yet crews and 
passengers are almost daily exposed to the perils of shipwreck 
in unsea worthy vessels, especially in the mercantile marine. ~ 

" Dampness, dirt, foul air, and darkness," according to 
Gihon, " are the direst enemies with which the sailor has to 
battle when afloat." 3 The first requisite for a healthy ship is 

1 Hence called " bilge- water." 

2 The Safety of Ships and Those who Travel in Them, Woodworth, Public Health, 
vol. hi, p. 79 et seq. 

* Naval Hygiene, 3d ed., p. 28. 



266 TEXT-BOOK OF HYGIENE. 

dryness. "A damp ship is an unhealthy ship," says Fonssa- 
grives, the greatest authority on naval hygiene. From official 
reports it appears that the relative humidity of the berth-deck 
of vessels in the United States navy is nearly always above 80 
per cent., very often rising to 90 and 95 per cent. 1 From the 
same source it is learned that the class of respiratory diseases 
furnished, with one exception, the largest amount of sickness in 
the navy during the year 1880. It is the concurrent testimony 
of all authorities in marine hygiene that the vicious custom of 
daily drenching the decks with water, under the plea of cleanli- 
ness, is mainly responsible for this excessive moisture and its 
results. The battle of naval hygiene was long fought on this 
contested field of wet decks, until the fact became so patent that 
wet ships were always unhealthy ones. It is, therefore, one 
of the most important aims of marine hygiene to curtail this 
practice. 

Gihon recommends that the decks be painted and then 
coated Avith shellac, occasionally renewed, to make them non- 
absorbent, and to wet them as rarely as possible, consistent with 
cleanliness, the smooth surface of the shellacked deck being 
quickly swabbed over with hot water and thoroughly dried. 

The ship should be clean and well ventilated. Efforts to 
keep a ship clean should not be expended upon the decks only; 
the occupied apartments below the hatches, the bilges and frame- 
spaces should all receive especial attention from the sanitary 
inspector. 

It is quite frequently necessary to remove the flooring of 
the vessels in order to expose the accumulations of filth, which 
often make an infected ship synonymous with a dirty ship. An 
unobstructed passage, to which ready access can be had through 
removable covers, should extend under the flooring from one 
end of the vessel to the other. To disinfect a dirty ship, steam 
forced into the hold under pressure, before and after the filth 
has been cleaned out, gives the most satisfactory results. 

1 Report of Surgeon-General of the Navy, Washington, 1880. 



THE SHIP AS A HABITATION. 267 

Chlorine and fumes of sulphur burned in the presence of watery 
vapor are next in efficiency. 1 Solutions of sulphate of iron 
or chloride of zinc may be poured into the bilges to prevent 
decomposition. 

It has been estimated 2 that a minimum of 15 cubic metres 
of air-space, with facilities for thorough ventilation, should be 
allowed to each person on board ship. It is safe to say that no 
vessel that floats gives to her passengers or crew the advantages 
of such conditions. Ventilation of the holds and bilges, and of 
the spaces between the frames or ribs, — " intercostal ventilation." 
as Turner calls it, — is especially necessary. Any system of ven- 
tilation that does not contemplate the removal of the foul 
bilge-air is unworthy of consideration by the sanitarian. The 
ventilating apparatus which has been introduced on board the 
modern vessels of the United States navy consists essentially of 
longitudinal mains extending through the entire length of the 
ship, connecting with powerful fan-blowers usually located on 
the berth-deck nearly amidships. In large vessels four blowers 
are fitted, each being connected with an independent system of 
pipes and all fitted with reversible valves, so that they may be 
used either for exhausting foul air or supplying fresh, and also 
fitted so that the fan systems can be used in combination, thus 
simultaneously exhausting foul air from and supplying fresh 
air to any compartment in the vessel. These blowers are 
driven at about four hundred revolutions per minute and are of 
sufficient power to maintain a vacuum of a half-inch below the 
atmosphere throughout the entire systems of pipes. Small 
metal pipes connect these longitudinal mains with every state- 
room, store-room, pantry, and other inclosed apartment on the 
berth-deck, orlop, and holds. All the openings in these pipes 
are bell-mouthed and fitted with wire gauze and registers, with 
a clear opening equal to twice the area of the pipe. Additional 
ventilating pipes are led from t«he bilges, wherever necessary, up 

1 Report of Committee on Disinfectants, American Public Health Association. 
9 "Hygiene of Emigrant Ships," Public Health, vol. vi, p. 26. 



268 TEXT-BOOK OF HYGIENE. 

the sides of the vessel, terminating in brass louvres inside the 
bulwarks, these being- also fitted with additional louvres between 
decks, especial care being taken to prevent the foul air from the 
bilges thereby reaching the living-spaces. 

Fresh air finds its way below through the wind-sails, venti- 
lating- shafts, hatchways, and air-ports, entering the apartments 
by way of doors, crevices, and other natural apertures. The 
absolutely essential condition of this system of ventilation is that 
the blowers shall revolve, but, unfortunately, sanitary interests 
are too often sacrificed on the pretext that economy of fuel will 
not permit the operation of the fan. 1 

All parts of the vessel used as habitations or sleeping- 
apartments should receive sufficient sunlight. At present, very 
few vessels have the quarters of the crew so disposed as to admit 
any sunshine at all. 

In the fire-rooms of steam-ships, especially on that class of 
naval vessels termed monitors, the temperature often rises so 
high as would seem to render continued existence in it impos- 
sible. Gihon states that the average temperature in the fire- 
room of the monitor Dictator was 145° F. (63° C), while 
Turner states that in another vessel the average fire-room tem- 
perature was 167° F. (75° C.). 2 The firemen and coal-heavers 
(stokers) frequently suffer from heat-stroke, and, in a very large 
proportion of cases, from heart disease. 

Lavatories and bathing facilities should be furnished on 
vessels for passengers and crew, and both should be compelled 
to keep their bodies and clothing clean. A more liberal supply 
of water for drinking, a more frequent issue of fresh meat and 
vegetables, and better cooking are the sanitary considerations 
to-day in the subsistence of the sailor. The American naval 
ration is superior in variety, nutrient value, and palatableness 
to that of any foreign service; but skilled cooks are still a de- 
sideratum on board men-of-war, and medical officers have long 
been insisting that schools for their instruction should be estab- 

1 Hygiene (Naval), Hand-book of the Medical Sciences, Gihon. 
a Buck's Hygiene and Public Health, vol. ii, p. 190. 



THE SHIP AS A HABITATION. 



269 



lished at recruiting stations. The composition and distribution 
of the rations are given in the following table : — 

Table XXIY. 

Allowance for General Daily Use. 

(Either one of the following.) 



Rations Established 
by Law. 



Specified by Law. 



Substitutes Authorized by Law. 



Ration No. 1 



Ration No. 2 



Ration No. 3 



Ration No. 4 



1 lb. salt pork J 

£ pint beans or peas . . 

1 lb. salt beef .... 

£ lb. flour ....... 

2 oz. dried fruit .... 

£ lb. preserved meat . 

£ lb. rice 

2 oz. butter . . 

1 oz. desiccated mixed 
vegetables x 

f lb. preserved meat . . 

2 oz. butter ....... 

6 oz. desiccated tomatoes 1 



1^ lb. fresh meat ; or, 
£ lb. preserved meat. 
Vegetables of equal value ; or, 



1£ lb. fresb meat ; or, 
£ lb. preserved meat. 
Vegetables of equal value. 

No substitute. 

£ pint beans or peas. 

No substitute. 

6 oz. canned vegetables. 

No substitute. 
No substitute. 
6 oz. canned tomatoes. 



DAILY ALLOWANCE. 



Specified by Law. 



Substitutes Authorized by Law. 



14 oz. biscuit 



4 oz. sugar 



1 lb. soft bread. 

1 lb. flour. 
£ lb. rice. 

2 oz. coffee. 
2 oz. cocoa. 

For coffee and sugar, extract of coffee 
combined with milk and sugar may 
be substituted by the Secretary of the 
Navy, if not more expensive . 



WEEKLY ALLOWANCE. 


Specified by Law. 


Substitutes Authorized by Law. 


^ pint pickles 2 


None. 


£ pint molasses 


None. 


^ pint vinegar 


None. 







1 These articles being out of the market, and not procurable, the nearest possible sub- 
stitutes are given. 

3 One-half pint pickles is considered equal to one-half pound, and is issued as such. 



270 



TEXT-BOOK OF HYGIENE. 



The substitutes authorized by law permit nine variations 
of ration No. 1, six of ration No. 2, three of ration No. 3, and 
two of ration No. 4. 

The quantity of fresh vegetables authorized is to be equal 
in value to any or all of the articles usually issued with the 
salted meats, for which they may be substituted, the allowance 
fixed for issue being one and one-fourth pounds per ration. 

Dried fruit may be either dried apples, peaches, raisins, 
currants, prunes, figs, dates, or any other dried fruit. 

Preserved meat comprises roast or compressed beef, Chi- 
cago corned beef, fresh mutton, or any other canned preserved 
meat, ham, brawn, bacon, sausage, salt fish, and any other salted 
or smoked preserved meat. 

In addition to these, the daily allowance of fourteen ounces 

Table XXY. 
United States Navy Sea- or Salt- Ration. One Week's Issue. 





Allowance. 


Nutrients in Grammes. 


CO 
Ed 

© c8 


•S3 • 

33 ►, © 


Articles. 


Lb. 


Oz. 


Protein. 


Fats. 


Carbo- 
hydrates. 


© t* o 
O fl <S 


Salt pork 1 

Salt beef 1 ... 
Preserved meats 2 . . 
Canned vegetables . 

Rice 3 

Peas 


2 
1 
4 
1 


2 

8 
8 

2 
4 
6 

12 
8 
6 
8 
1.50 


194.14 

115.78 

23133 

13.77 

16.78 

60.55 

104.78 

49.89 

433.41 

2.72 

1.70 


52.05 
0.78 

69.40 
2.04 
0.90 
3.85 
9.07 
4.98 

36.11 

' 144.58 


' 66.33 
180.07 
127.91 
270.53 
339.74 

2039.27 

70.30 

0.85 

776.33 

165.79 


163.57 
82.0 
32.16 

0.90 
6.57 

14.06 
2.26 

24.23 

5.10 




Beans ." 

Flour 3 

Biscuit 

Dried fruit 

Butter 


1 
1 
6 




Sugar 

Molasses 


1 




Cocoa *. . 




' 


Coffee 






Tea 






Vinegar and pickles 


1 




Total 


22 


1.50 


1224.85 


323.76 


4037.12 


330.85 




Daily average . . 


3 


0.35 


174.98 


46 25 


576.71 


47.26 


3515 



1 Eighteen per cent, waste. 

9 Corned beef, roast beef, and sausage meat. 

Substitutes : Ham, brawn, bacon, smoked and salt fish. 
* Or cornmeal, hominy, oatmeal. 



DISEASES ON SHIPBOARD. 



271 



Table XXVI. 

United States Navy Fresh Ration. Average Daily Issue. 





Allowanck. 


Nutrients in Grammes. 


Mineral 
Matters. 


33 >>.£ 


Articles. 


Lb. 


Oz. 


Protein. 


Fats. 


Carbo- 
hydrates. 


O z ci 


Fresh meats i . 
Fresh vegetables 2 . 
Fresh bread .... 

Flour 

Butter 


1 
1 
1 


4.0 
4.0 

2 28 

0.85 

4.0 

1.14 

0.57 

0.85 

1.14 

0.18 

2 28 


87.68 

10.71 

37.71 

7.12 

0.08 

' 0.39 


74 48 
0.43 
7.71 
0.72 

21.99 


74.19 

255.37 

48.53 

110.90' 
23.80 
10.04 


4.35 
4.08 
3.98 
0.32 
0.22 




Sugar 

Molasses 






Dried fruit 






Cocoa 






Coffee 






Tea 






Pickles and vinegar. 






Total 


4 


5.29 


143.69 


105.33 


522.83 


12.95 


3715 



The Daily Average United States Naval Ration. 

Protein 157.34 

Fats . . 75.59 

Carbohydrates 549.77 

Mineral matters 30 10 

Potential energy in calories . . . 3615 
Potential energy in foot tons . . . 5531 



The mean of all food-supplies 



of biscuit can be varied by the substitution of one pound of soft 
bread, or one pound of flour (which may be either wheat, rye, 
cornmeal, oatmeal, or hominy), or one-half pound of rice. 3 

Surgeon Charles A. Siegfried, of the United States navy, 
has tabulated the American naval ration according to its nutrient 
value. 4 (See Tables XXV and XXVI.) 

IV. — DISEASES ON SHIPBOARD. 

The diseases most liable to attack persons on shipboard 
are : Diseases of the respiratory organs, rheumatism, malarial 
diseases, digestive disorders, scurvy, typhus fever, and skin 
diseases ; and, where the infection has been conveyed to the 

1 Twenty per cent, waste. Calculated from total fore and bind quarters. 
3 Eighteen per cent, waste. Potatoes, onions, cabbage, etc., mixed. 
3 U. S. Navy Ration Regulations, 1884. 
* Journal of American Medical Association, December 31, 1892. 



272 TEXT-BOOK OF HYGIENE. 

vessel by other persons or by fomites, yellow fever, cholera, 
small-pox, and venereal diseases. It is interesting to note, in 
a recent report of the Surgeon-General of the Navy, that, among 
a total of 8550 admissions of sick and disabled officers and 
men of the navy and marine service, nearly 90 per cent, were 
included in the following classes, to wit : — 

Casualties, 191? 

Affections of the respiratory tract, . . . 1149 

Venereal diseases, 1071 

Malarial and other fevers, 888 

Diseases of the integument, . . . 888 

Rheumatism, 521 

Affections of the nervous system, . . . 489 

Diarrhceal maladies, ...... 483 

The remaining 1144 were distributed over a wide range of 
titles, of which many, as adynamia, cephalalgia, constipation, 
odontalgia, etc., have no special pathological significance. It is 
probable that only about one-fourth of the cases of disease 
occurring at sea are attributable to any of the circumstances of 
oceanic life, and these are almost entirely inflammatory affections 
of the air-passages and intestinal tract, neuroses, including 
nausea marina, and rheumatism. 1 

Most of these affections can be prevented by proper meas- 
ures of hygiene, as demanded by the conditions described in this 
chapter or by the enforcement of the following regulations : — 

Inspection of crews and passengers should be made com- 
pulsory before shipment. Persons suffering from contagious or 
infectious diseases should not be taken on board. 2 In order to 
make this provision effective, the history of the individual for 
two weeks prior to his application for shipment should be known 
to the inspecting officer. Passengers should possess bills of 
health from the local authorities at their homes, in order that 

1 "The Therapy of Ocean Climate," Gihon, Transactions of American Climatological 
Association, 1889. 

* Gihon relates an instance -where a man suffering from parotitis was transferred from 
the hospital of a receiving-ship to a vessel going to sea. The disease was communicated to 
more than seventy of the crew of the latter vessel. 



DISEASES ON SHIPBOARD. 273 

the presence or absence of such diseases as small-pox, yellow 
fever, cholera, or plague may be established by the inspector. 
Cholera has always been introduced into this country by immi- 
grants. Everybody admitted to the ship should be vaccinated. 
During several years past a number of epidemics of small-pox 
have been traced to foreign immigrants who had not been 
properly vaccinated. 

Sailors in the merchant service should, like those in the 
navy, be submitted to a close personal inspection, and those 
suffering from venereal diseases should be rejected. The usual 
history of the cases is that tiiey soon go on the sick-list, and 
thus become an incumbrance instead of an aid on the vessel. 
Statistics show that 1 man in every 7 or 8 in the naval service 
and 1 in every 4 of the crews of merchant vessels are affected 
with some form of venereal malady. 1 These inspections should 
not be restricted to examinations for venereal diseases, but indi- 
viduals incapacitated for the performance of a seaman's duties 
by any cause should be rejected. This precaution would un- 
questionably reduce the number of marine disasters directly 
traceable to deficiency in the working force on board vessels. 
In this country the services of the medical officers of the Marine- 
Hospital Service might be made available to carry out these 
inspections. 

All sailors are liable to be placed in positions where the 
prompt and accurate distinction of colors becomes necessary; 
hence all color-blind individuals should be rejected as seamen. 
The inability to distinguish colors has often been the cause of 
grave accidents at sea. Pilots can no longer obtain a license 
unless they satisfactorily pass an examination with reference to 
their ability to distinguish colors. 

The protection of the passenger on shipboard, as well as 
the safeguarding of a country against the introduction of 
exotic epidemic diseases, demands that the sanitary and medical 
service on board emigrant ships shall be the best attainable. 

1 "The Prevention of Venereal Diseases," Gihon, Public Health, 1882. 

18 



274 TEXT-BOOK OF HYGIENE. 

At present there are still many short-comings. A recent report 
made to the American Public Health Association, by a com- 
mittee appointed for the purpose, gives an authoritative ex- 
pression of opinion upon these points. The committee advise: 

" 1. As to the location and dimensions of the quarters for 
emigrant passengers, the number of berths in each, and the 
provisions for their ventilation and cleansing : 

" That the preferable location for such quarters is abaft the 
midship section of the vessel ; that single males' quarters shall 
be distinct from those occupied by women and children, and 
that, if any are forward the midship section, it shall be those for 
single men. 

" That there shall never be more than two decks (properly 
there should be only one) occupied by emigrant passengers' 
berths, with sixteen feet of superficial space for each adult on 
the upper berth-deck and twenty feet of such space on the 
lower berth-deck, with not more than two tiers of berths on 
each deck, the bottom of the lower tier being not less than 
eighteen inches above the deck, with not less than thirty 
inches between the two tiers and between the upper tier and 
the ceiling of the compartment, to allow the occupants of the 
berths to sit upright. 

"That no solid partitions or bulkheads shall be placed in 
any steerage compartment to obstruct light and air. 

"That the frame-work of the berths shall be of iron, easily 
removable, that the compartment may be completely emptied 
and thoroughly cleaned after each passage. 

" That a steam ventilating apparatus by aspiration shall be 
introduced into all emigrant vessels ; and 

" That all compartments occupied by passengers and crew 
shall be lighted by the incandescent electric light by night and 
by day. 

" 2. As to the location and dimensions of hospitals on 
board such vessels and the number of sick-berths for which 
provision should be made : 



DISEASES ON SHIPBOARD. 275 

" That the hospitals, or ■ sick-bays,' on board emigrant pas- 
senger vessels shall be at the extreme after part of the upper 
deck, thoroughly lighted and ventilated, with eighteen feet of 
superficial space for every fifty passengers, and not less than 
four sick-berths or hospital cots for every hundred passengers. 

" 3. As to the number of medical officers proper for the 
maximum of emigrant passengers any vessel should be per- 
mitted to carry, being the maximum number able to be berthed 
with regard to health, cleanliness, and comfort : 

"That there should be one duly-qualified medical officer 
for every two hundred and fifty passengers. 

"4. As to the professional records which the senior medical 
officer of every such vessel should be required to keep, and his 
responsibility to the health authorities of the port of arrival 
for the truthful and professionally-accurate statements of such 
records : 

" That the senior medical officer of every such vessel shall 
be required to keep (1) a list of sic7t\ recording in a bound book, 
in the order of their admission, and on a single line, the name, 
sex, age, birthplace, date of admission to treatment, date of 
death or discharge from treatment, disease, and such remarks 
as may be necessary to enable the inspecting medical officer at 
the port of arrival to have a clear and complete understanding 
of the case; (2) a medical journal, in which each medical 
officer, when there are more than one, shall record the medical 
history, including symptoms and treatment of every case, to be 
approved and signed by the senior medical officer at the close 
of the day's record ; and such list of sick and medical journal 
shall be submitted to the health authorities of the port of arrival, 
and the accuracy of the statements in such records shall be 
established by oath, and penalties for perjury shall be provided. 

" 5. As to the location and capacity of latrines for emigrant 
passengers : 

"That the latrines — shallow troughs with a continuous 
flow of salt water — shall be on the upper deck, under shelter, 



276 TEXT-BOOK OF HYGIENE. 

with two water-closet seats for every fifty passengers, with a 
proportionate number for women and children, in a separate 
locality, near their own quarters, inaccessible to men. 

" 6. As to the number of attendants provided for such pas- 
sengers, and their duties as to policing and cleansing emigrants' 
quarters : 

" That there shall be not less than one berth-deck attendant 
for every fifty passengers, female attendants in the same propor- 
tion being exclusively assigned to the quarters for women and 
children. 

" That the berth-decks shall be thoroughly cleansed every 
morning by the attendants, never wetted in rainy or damp 
weather, when they shall be scraped, swept, and freshly sanded ; 
and in pleasant weather washed with hot water and quickly 
dried, the passengers being sent on deck during the operation. 

" That the berth- deck attendants shall be on duty night 
and day in rotation by regular sea watches, and the attendants 
on watch required to remove the dejecta of seasick passengers 
without delay. 

" That benches and mess-tables shall be provided, and the 
passengers' food be distributed by the berth-deck attendants, 
who shall take away all unused food and carry the dishes to 
the pantry. 

" 7. As to additional provisions for the personal health, 
cleanliness, and comfort of emigrant passengers : 

" That wash-rooms, under cover, with basins supplied with 
running water, shall be provided on the upper deck ; those for 
men to be separate from those intended for women and children. 

" That fresh water for drinking purposes shall be provided 
in each compartment ; and 

" That inexpensive mattresses, pillows, — these to be service- 
able as life-preservers, — and blankets shall be provided for emi- 
grant passengers, the mattresses to be destroyed after each 
passage, and the pillows and blankets to be steamed and 
washed before being again used." 



DISEASES ON SHIPBOARD. 277 

[The following works contain more detailed information 
upon the subject treated in the foregoing chapter : — 

Albert L. Gihon, Practical Suggestions in Naval Hygiene, 3d ed., 
Washington, 1873. — T. J. Turner, Hygiene of the Naval and Merchant 
Marine. — Buck's Hygiene and Public Health, vol. ii. — Walter Wyman, 
Hygiene of Steam-boats on the Western Rivers. — Report of Supervising 
Surgeon-General M. H. Service for 1882. — Annual Reports of the Surgeon- 
General of the Navy for 1879, 1880, and 1881.— Various papers by J. M. 
Woodworth, Albert L. Gihon, T. J. Turner, Hebersmith, and A. N. Bell 
in Public Health, vols, i, iii, and vi. — Hygiene, Naval, by Albert L. Gihon, 
M.D., in Reference Hand-book of Medical Sciences.] 



QUESTIONS TO CHAPTER XL 
Marine Hygiene. 

What is meant by marine l^giene ? In what respects is the condi- 
tion of the sailor in the United States navy now better than formerly ? 
Is the merchant sailor as fortunate ? 

How does the death-rate on passenger vessels compare with that on 
shore ? What are some of the causes of the excessive mortality among 
steerage passengers ? In what ways can these causes be prevented ? 

What are the principal points about a ship in which the sanitarian is 
interested ? What tends to pollute the air of a ship ? What is meant 
by the bilge and bilge-water ? By the frame-spaces ? 

Where are the sleeping apartments usually of a merchant crew ? 
Of a naval crew ? What are the faults of each ? What are the sailor's 
greatest enemies when afloat? What is the first requisite for a healthy 
ship ? What is the relative humidity of the berth-deck in most United 
States naval vessels ? To what is this excessive humidity largely due ? 
How might this be avoided ? What class of diseases is especially preva- 
lent in the navy ? 

How else may the sanitary condition of a vessel be improved ? What 
is meant by a clean ship ? How may a dirty ship be disinfected ? Where 
is ventilation especially necessary on a vessel ? 

What amount of air-space should be allowed each person on board 
ship ? Is this customarily provided for ? Describe the ventilating appa- 
ratus of vessels of the United States navy. Upon what does the efficacy 
of this depend, and in what respect is it faulty ? Do the sleeping-apart- 
ments of vessels receive sufficient sunlight ? To what maladies are the 
firemen and coal-heavers of steam-vessels subject? What other con- 
siderations affect the health of the sailor ? 

What are some of the diseases most liable to attack persons on ship- 
board ? What is the probable order of frequency ? What proportion 
are really attributable to the sea-life ? How can most of the affections 
be prevented ? What hygienic regulations should be enforced both be- 
fore and after embarkation. Why ? With what should each passenger 
be provided? What sailors should be rejected and not enlisted? What 
may happen if this course is not followed ? What officers might carry 
on the inspection in this country ? 

(278) 



CHAPTER Xn. 
Prison Hygiene. 

Although the frightful mortality which formerly seemed a 
necessary accompaniment of the life of the convict has in the 
past half-century markedly diminished, the death-rate among 
prisoners is still very greatly in excess of that of persons of the 
same age in a state of liberty. 

The observations and labors of John Howard, the self- 
sacrificing philanthropist, in the latter half of the last century, 
and of Elizabeth Fry, in the first half of the present, directed 
the attention of legislators to the necessity of reform in the con- 
duct of prisons and the treatment of prisoners. As a conse- 
quence of the labors of these reformers, the principles of prison 
discipline have been more fully developed during the past forty 
years by students of social science everywhere, and certain 
propositions have been formulated, which govern, to a greater 
or less degree, legislation upon this subject. These propositions 
are, briefly, as follow : — 

Prisoners must be properly classified according to the 
nature of their crime and the duration of imprisonment. 

The two sexes must be strictly separated, and no oppor- 
tunity given for intermingling while in the prison. 

Female prisoners should have female attendants exclusively. 
Male watchmen or other attendants should not be allowed in 
the female department of a prison. 

All prisoners must be kept employed at some manual labor, 
not necessarily for profit, but as an agency in the moral reforma- 
tion of the convict. 

Punishments for infractions of discipline must not be 
excessive. 

(279) 



280 TEXT-BOOK OF HYGIENE. 

Efforts should be constantly made tending to the reclama- 
tion of criminals from their life of sin and crime. 

Due care must be taken by the State to preserve the health 
and life of the prisoner whom the State has deprived of liberty 
and the opportunity of taking care of himself. 

A proper classification of prisoners, according to the degree 
of their criminality, the nature of the crime of which they have 
been convicted, or the length of time for which they have been 
sentenced, is now insisted upon by all students of prison dis- 
cipline. As this subject more nearly concerns the social or legal 
relations of prisoners rather than their sanitary interests, it is 
here passed over with a mere mention. 

The separation of the sexes, necessity of female attendants 
on prisoners of the same sex, employment of prisoners, and moral 
reformation of criminals likewise belong especially to the social 
aspects of the question, and can find no discussion in this place. 

Regarding the remaining proposition, however, that which 
demands that the State shall exercise due care over the prisoner's 
health, it comprises a question that demands consideration in a 
text-book on hygiene. 

There is now a general concurrence of opinion that the 
State, in depriving any person of liberty, has no right to subject 
the individual suffering such deprivation to any danger of disease 
or death. In other words, the State has no right to abbreviate 
the life of the convict sentenced to prison. This proposition 
requires that the State see to it that the prisoner is well fed, 
well clothed, and well housed ; that he shall be well cared for 
when sick, and that when his term of imprisonment expires he 
shall be set at liberty, with only such effect upon his normal 
expectation of life as would result from the ordinary wear and 
tear of life upon his health. 

It must be confessed, however, that the State is very far 
short of attaining this object. The mortality of convicts, even 
in the best-regulated prisons, where especial attention is paid to 
the sanitary requirements of such buildings, is three times as 



PRISON HYGIENE. 281 

great as among workmen in mines, confessedly one of the most 
dangerous occupations. If insurance companies desired to 
insure the lives of prisoners, the companies would be obliged, in 
order to secure themselves against loss, to make the premium 
equivalent to an advance in age of twenty years. This means 
that a free person has as long an expectation of life at 40 
years as a prisoner has at 20. Attention is again called to 
the fact that the conditions in the most favorably situated and 
liberally managed prisons only are here considered. What the 
results are in other institutions, less favorably constructed and 
managed, will be apparent from the following brief statement : 
Mr. George W. Cable has shown 1 that in some of the prisons 
in the Southern States, under the vicious lease system, the 
mortality is eight to ten times greater than in properly con- 
structed and managed prisons elsewhere. In Louisiana, for 
example, 14 per cent, of all the prisoners died in 1881 ; and in 
the convict wood-cutting camps of the State of Texas one-half 
of the average number so employed during 1879 and 1880 died. 

The mortality of prisoners is greatest in the second, third, 
and fourth years of their confinement. In Millbank Prison, in 
England, the death-rate per 1000 was 3.05 in the first year, 
35.64 in the second, 52.26 in the third, 57.13 in the fourth, and 
44.17 in the fifth years of imprisonment. 

The diseases most frequent among prisoners are pulmonary 
phthisis and diseases of inanition, manifested by general dropsy. 
Consumption furnishes from 40 to 80 per cent, of all deaths. 
When prisoners are attacked by acute febrile or epidemic diseases 
(small-pox, cholera, dysentery), the mortality is much higher 
than among persons in a state of liberty. This fatality is due 
to an anaemic or cachectic condition, which has been called " the 
prison cachexia;" — a depravement of constitution which yields 
readily to the invasion of acute diseases. 

Prisons should be built upon a healthy site, be properly 
heated and ventilated, have an abundant water-supply, and 

* Century Magazine, February, 1884. 



282 TEXT-BOOK OF HYGIENE. 

be supplied with facilities for a prompt and thorough removal 
of sewage. Baths and lavatories should be conveniently ar- 
ranged in order that thorough cleanliness can be enforced. 

The problem of feeding prisoners requires careful study. 
The food should not only be sufficient in quantity and of good 
quality, but it should be well cooked, and the bill of fare varied 
often in order to avoid creating a disgust by an everlasting 
sameness. Prisoners often suffer from nausea and other digestive 
derangements, brought on solely by the monotonous character 
of the daily food. 

In workshops and sleeping-rooms, dormitories or cells, the 
cubic air-space allowed to each inmate should not be less than 
17 cubic metres, with proper provision for ventilation. The 
use of dark or damp cells as places of confinement is a relic of 
the barbarism in the treatment of convicts against which John 
Howard raised his voice so effectively in the last century. An 
abundance of sunlight should be admitted into every room in 
which a human being is confined. 

An important hygienic measure is daily exercise in the 
open air. It should be regularly enforced, and its modes 
frequently varied in order that it may not degenerate into a 
mere perfunctory performance. 

Punishment for infractions of the prison discipline should 
be inflicted without manifestation of passion, and only under the 
immediate direction of some official responsible to the State. 
It is questionable whether physical punishments, such as 
whipping, tricing up by the thumbs with the toes just touching 
the floor, bucking and gagging, and similar barbarities should 
be permitted under any condition. The permission to exercise 
such power is extremely liable to be abused by officials. The 
system of leasing out prisoners to private parties, which prevails 
in some of the southern United States is vicious in the extreme, 
because it places the convict under the control of persons not 
responsible to the State, and, in the majority of instances, morally 
unfitted to wield the power of inflicting punishment. 



PRISON HYGIENE. 283 

[The following works on prison hygiene and prison reform 
are recommended to the student : — 

A. Baer, Gefangniss-Hygiene, in von Pettenkofer und Ziemssen's 
Handbuch der Hygiene, II Th., 2 Abth. — Trans. International Peniten- 
tiarj- Congress, London, 1882. — Trans. National Prison Association, 
Baltimore, 1872. — G. W. Cable, The Convict-Lease System in the South- 
ern States, Century Magazine. February 1884. J 



QUESTIONS TO CHAPTER XII. 

Prison Hygiene. 

How does the mortality of those who are in prison compare with 
those of the same age who are free ? What philanthropists called early 
attention to the abuses of prisons and prisoners ? What fundamental 
propositions now practical^ govern prison legislation ? Why must the 
State exercise due care over the prisoner's health ? What must the State 
do to attain this object? Does it succeed in doing it? How does the 
excessive mortalit} T compare with that of dangerous occupations ? How 
does the expectation of life compare with that of those outside of 
prison ? What is the mortality where the lease-system obtains ? When 
is the mortality among prisoners greatest? What diseases are most 
frequent among prisoners ? What is the effect of acute febrile or 
epidemic diseases upon prisoners ? To what is this due ? 

What principles should be observed in prison construction ? What 
points should be particularly observed regarding the food of prisoners ? 
How much air-space should be allotted to each prisoner, whether in 
workshops or cells ? What precautions should be taken against damp- 
ness and absence of sunlight ? What is another important measure that 
should be enforced daily ? How should all punishments be inflicted, and 
what ones should be prohibited ? What can be said of the lease system ? 



(284) 



CHAPTER XIII. 

Exercise and Training. 

The healthy functions of the bodily organs can only be 
maintained by more or less constant use. A muscle or other 
organ that is unused soon wastes away, or becomes valueless to 
its possessor. On the other hand, trained use of the various 
organs makes them more effective for the performance of their 
functions. Thus, by practice, the eye can be trained to sharper 
vision, the ear to distinguish slight shades of sound, the voice to 
express varying emotions, the tactile sense to accurately appre- 
ciate the most minute variations of surface and temperature, and 
the hand to greater steadiness or the performance of difficult 
and complex feats. The effectiveness of other organs, muscles, 
or groups of muscles can also be increased, by systematic train- 
ing, as is seen in the athlete and gymnast. 

PHYSIOLOGICAL EFFECTS OF EXERCISE. 

When a muscle contracts, the flow of blood through it is 
increased. Hence, contraction of a muscle, which consumes or 
converts stored-up energy, at the same time draws upon the cir- 
culation for a new supply of food-material to replace that con- 
sumed. VThe activity of the circulation through a muscle in 
action results in increased nutrition and growth of the muscle. 

During muscular action the activity of the respiratory 
process is increased. A larger quantity of air is taken into the 
lungs, more oxygen is absorbed by the blood, and an increased 
elimination of carbon dioxide takes place. The experiments of 
Pettenkofer and Voit show that, while in a state of rest the 
average absorption of oxygen in twelve hours amounted to 708.9 
grammes, during work the amount reached 954.5 grammes. 

(285) 



286 TEXT-BOOK OF HYGIENE. 

For the same period the elimination of carbonic dioxide was: 
during rest, 911.5 grammes; during work, 1284.2 grammes. 

Upon the circulation muscular exercise likewise exerts a 
manifest influence. The action of the heart is increased both in 
force and frequency, the arteries dilate, and the blood is sent 
coursing through the system more rapidly than when the body 
is at rest. 

Cutaneous transpiration is also promoted by muscular exer- 
cise. It is probable that in this way some of the effete matters 
in the system are removed, being held in solution and carried 
through the skin in the perspiration. 

PHYSICAL TRAINING. 

There can be no question that systematic training of the 
muscles has a favorable influence upon health and longevity. 
Persons who are actively engaged in physical labor, other things 
being equal, are healthier, happier, and live longer than those 
whose occupation makes slight demands upon their muscular sys- 
tem. In default of an active occupation the latter class is forced, if 
good health is desired, to adopt some form of exercise which 
will call the muscles into activity. 

The principal methods of physical training are walking or 
running, rowing, swimming, and the various in-door gymnastic 
exercises. Rapid walking or running is one of the best methods 
of physical exercise, for, not only are the muscles of the legs and 
thighs developed, but the capacity of the chest is increased — one 
of the principal objects of physical training. By combining 
walking with some form of in-door gymnastics, such as practice 
with dumb-bells, Indian clubs, rowing-machines, or pulley- 
weights, nearly all the good effects of the most elaborate system 
of training can be obtained. 

For the gymnastic exercises various forms of useful labor 
may be substituted with advantage, such as wood-chopping or 
sawing, or moderate work at any physical labor. 

The scheme of studies in our public-school system should 



PHYSICAL TRAINING. 287 

include physical training for both sexes. This is a question not 
merely of individual, but of national importance. Weak and 
unhealthy children are not likely to grow up into strong and 
healthy men and women; and the latter are necessary for the 
perpetuity of the nation. The time seems to have arrived when 
physical education should no longer be looked upon as a whim 
of unpractical enthusiasts and hobby-riders, but as an indispen- 
sable element in every school curriculum. 

There is a tendency among instructors in physical training 
to make their systems too complicated, or dependent upon expen- 
sive or cumbersome apparatus. This is to be deprecated. All 
the muscles of the body can be called into action by very simple 
exercises, easily learned and readily carried out. 

An important preliminary to all methods of training is a 
thorough physical examination of the pupil by a competent 
physician, in order to determine whether certain exercises are 
allowable. For example, in all organic heart affections exer- 
cises of a violent character must be interdicted. A boy or man 
with valvular disease of the heart cannot run, row, or swim 
with safety. The organ is easily overtasked in this condition 
and liable to fail in its function. 

One of the simplest and best methods to cause the pupil to 
assume a correct position of the body, and to acquire ease and 
grace in his movements, is to teach him the "setting-up/' as 
practiced in the United States army. 1 

In walking, a free, swinging step should be acquired, with 
the head erect, shoulders thrown back, and chest well to the 
front, the whole body from the hips upward inclining slightly 
forward. The clothing should be loose around the upper part 
of the body, in order not to interfere with the freest expansion 
of the chest, and to give the lungs and heart ample room for 
movement. Even in-door gymnastic exercises alone, when prac- 
ticed under intelligent provision, will accomplish very favorable 
results, as shown by the following table: — 

1 Upton's Infantry Tactics. School of the Soldier, Lesson I. 



288 



TEXT-BOOK OF HYGIENE. 



Table XXYII. 

Shotting Average State of Development on Admission to Gymnasium ; Average State 
of Growth and Development after Six Months' Practicing Two Hours a Week, 
and Average Increase During that Time. {Boiodoin College Gymnasium, under 
Dr. D. A. Sargent. Two Hundred Students from the Classes of 1873 to 1877, 
inclusive. Average Age, 18.8 Tears.) 1 



Height 

Weight 

Chest (inflated) . 
Chest (contracted) 

Forearm 

Upper arm (flexed) 
Shoulders (.width) 

Hips 

Thigh 

Calf 



On Admission. 



170.0 cm. 
60.7 kg. 

87.5 cm. 

80.6 " 
25.0 » 
27.5 " 

38.7 " 
78.7 " 
48.7 " 
31.2 " 



After Six 

Months' 

Practice. 



170.6 cm. 
61.6 kg. 
91.8 cm. 

82.4 " 
26.8 " 
29.0 " 

40.5 " 
84.4 " 

52.6 " 
33.0 " 



Average 
Increase. 



0.6 cm. 
900.0 gms. 
4.3 cm. 
1.8 " 
1.8 " 
1.5 " 

1.8 " 

5.7 " 

3.9 " 

1.8 " 



The table on the following page shows the average rate of 
increase in development in a two years' and a four years' class 
in Amherst College, and also the percentage of increase in one 
four years' class from entrance to graduation. The interest- 
ing fact has been brought out by Mr. Delabarre that tobacco- 
smoking has a decidedly deleterious effect upon the rate and 
percentage of physical development in students. In weight 
non-smokers gained 24 per cent, over smokers ; in height 37 
per cent., and in chest-girth 42 per cent. 



OVEREXERTION. 

However necessary for the preservation of health physical 
exercise may be, overexertion should be carefully avoided. 
Overstrain and hypertrophy of the heart are often the results of 
excessive exertion. Dr. Da Costa has described a form of" irri- 
table " and weak heart occurring especially among soldiers, which 
he has clearly traced to overexertion. Severe labor and violent 
athletic exercises have been followed by like serious results. 
Long-distance pedestrianism has furnished, within recent years, 
quite a number of individuals who were broken down in health 



1 Apparatus used: Weights, 4500 to 6750 grammes; Dumh-bells, 1125 grammes; Indian 
clubs, 1575 grammes ; Pulleys. 



OVEREXERTION. 



289 



Table XXVIII. 

Showing Physical Gains of Students in Amherst College During a Part and During 
the WJiole of the College Course. (Prof. E. Hitchcock, Dr. H. R. Seelye, and 
Mr. F. A. Delabarre.) 



Weight 

Height 

Sternum 

Navel 

Puhes 

Knee 

Sitting 

Girth, Head 

Neck 

Chest repose .... 

Chest full 

Belly 

Hips 

Right thigh . . . . 

Left thigh 

Right knee 

Left knee 

Right calf 

Left calf 

Right instep . . . . 

Left instep 

Upper right arm . . 

U. R. A. contracted 

Upper left arm . . 

Right elbow . . . . 

Left elbow 

Right forearm . . . 

Left forearm . . . . 

Right wrist . . . . 

Left wrist 

Breadth, Head 

Neck 

Shoulders 

Nipples 

Waist 

Hips 

Right-shoulder elbow . 
Left-shoulder elbow . . 
Right elbow-tip . . . . 

Left elbow-tip 

Length, Right foot . . 

Left foot 

Stretch of arms . . . . 
Horizontal length . . . 
Strength 

Lungs 

Back 

Chest dip 

Chest pull up . . . 

Legs 

Right forearm . . . 

Left forearm . . . 
Capacity of lungs . . . 



Gain of Two 
Years' Class. 



Metric. 



*2. 



.11 

.3 

.4 

.8 

.4 

.14 

.5 

.10 

.14 

.9 

.10 

.15 

.19 

.13 

.4 



.11 
.2 
.2 
.13 
.11 
.14 
.6 
.6 
.4 
.3 
.1 
.2 
.1 
.2 
.11 
.7 
.2 
.2 
.3 
.2 
.2 
.2 
.2 
.1 
.19 
.14 
a. 73 

a. 30 

a2.8 

b2.6 
bl.l 

a. 33 
a. 5 
a. 5 

cl.2 



English. 



d5.72 
.43 
.11 
.15 
.31 
.15 
.55 
.19 
.39 
.55 
.35 
.39 
.59 
.74 
.51 
.15 
.11 
.35 
.43 
.07 
.07 
.51 
.43 
.55 
.23 
.23 
.15 
.11 
.03 
.07 
.03 
.07 
.43 
.27 
.07 
.07 
.11 
.07 
.07 
.07 
.07 
.03 
.74 
.55 

H60.9 
d.66 

d61.7 



a 72.7 
dll.O 
dll.O 

e73.2 



Gain of Four 
Years' Class. 



Metric. 



5.40 
.16 
.11 
.9 
.5 
.12 
.18 
.7 
.14 
.41 
.34 
.41 
.36 
.24 
.25 
.6 
.7 
.13 
.10 
.8 
.9 
.13 
.17 
.16 
.6 
.5 
.5 



.3 
.4 

.19 

.13 

.9 

.11 

.4 

.4 

.10 

.6 

.5 

.4 

.24 

.20 

.82 

.64 

.28 
2.3 
1.2 

.37 

.7 

.5 
3.6 



English. 



.63 
.43 
.35 
.19 
.47 
.7 
.27 
.55 
1.61 
1.33 
1.61 
1.41 
.94 
.98 
.23 
.27 
.51 
.39 
.31 
.35 
.51 
.66 
.62 
.23 
.19 
.19 
.23 
.07 
11 
.11 
.15 
.74 
.51 
.35 
.43 
.15 
.15 
.39 
.23 
.19 
.15 
.94 
.78 
180.8 
1.41 
61.7 



81.5 

15.4 

11.0 

219.6 



Per Cent. 

of 

Increase 

in Class 

of '91. 



0.6 
0.7 
1.2 
3.3 
0.4 
1.3 
0.5 
2.5 
3.0 
1.0 
4.1 
2.4 
3.0 
3.1 
0.8 
1.1 
2.8 
2.3 
0.8 
0.8 
6.3 
6.4 
7.8 
3.5 
3.5 
3.3 
3.1 
0.0 
0.6 
0.6 
1.8 
3.6 
6.4 
3.4 
1.8 
1.1 
0.8 
1.5 
1.5 
1.1 
1.1 
1.3 
0.6 
26.9 
27.8 
24.0 
38.0 
20.5 
26.0 
23.7 
15.6 
4.0 



Wei r . 



Height, 
272 



Girth, 

2.72 



Breadth, 
2.93 



Strength, 
25.31 



Capacity, 
4.00 



A total average gain 
of 5.87 per cent. 



a— Kilos, b— Units. 



c — Litres, d— Pounds, e — Cuhic inches, 
and Inches and Tenths. 



All others, Millimetres, 



by the excessive strain on the physical organization involved. 
Cardiac strain is not infrequent among this class. Spasm, 



19 



290 TEXT-BOOK OF HYGIENE. 

paralysis, or atrophy of muscles sometimes results, when these 
are exhausted by uninterrupted or excessive exercise. This 
effect is shown by writers' and telegraphers' cramp, and similar 
affections. For these reasons it is important that both exercise 
for health and actual work should be so regulated as to conduce 
to the individual's benefit, and not to his detriment. 

[On the subjects embraced in this chapter the following 
works may be studied with advantage : — 

A. Braynton Ball, ; ' Physical Exercise," in Buck's Hygiene and 
Public Health, vol. i. — Wm. Blaikie, How to Get Strong and How to 
Stay so. — A. Maclaren, Training in Theory and Practice. — Hitchcock 
and Seelye, The Amherst Anthropometric Manual.] 



QUESTIONS TO CHAPTER XIII. 

Exercise and Training. 

What is absolutely necessary for the maintenance of the healthy 
functions of the body ? What is the effect of disuse upon any organ ? 
Of training? 

What occurs when a muscle contracts ? What is the result of in- 
creased activity of circulation in a muscle ? What is the effect of mus- 
cular action on the respirator}' process ? What is the difference as to 
the absorption of oxygen in a state of rest and during work ? As to the 
elimination of carbon dioxide and water ? What is the effect of muscular 
action upon the circulation ? Upon the cutaneous transpiration ? 

What is the effect of S3 r stematic training upon health and longevity ? 
What are some of the principal and best methods of physical training? 
What is one of its most important objects? How may the various 
methods be combined with benefit? 

What should be included among the studies and work of all public 
schools ? For what purposes ? What is the tendency among instructors 
in physical training ? Is this necessary, or not ? Why ? 

What is an important preliminary to all methods of training? 
Why ? How may a pupil be taught to assume and maintain a correct 
position and carriage of the bod}' ? 

How should a person walk ? What attention should be given to the 
clothing worn during exercise ? What will be some of the results of 
systematic physical training properly pursued ? 

What are some of the results of overexertion? Does it make a 
difference whether the exercise is too long uninterrupted or whether it is 
excessive in amount and character ? 



(291) 



CHAPTER XIV. 

Baths and Bathing. 

The most important sanitary object of bathing is cleanli- 
ness. A secondary object of the bath is to stimulate the func- 
tions of the skin, and to produce a general feeling of exhilaration 
of the body. Baths are used of various temperatures. A cold 
bath has a temperature of from 4° to 24° C. (40° to 75° F.) ; a 
tepid bath from 24° to 30° C. (75° to 85° R), a warm bath from 
30° to 38° C. (85° to 100° F.), and a hot bath from 38° to 43° 
C. (100° to 110° F.). 

Tepid, warm, or hot baths are used principally as cleansing 
agents or as therapeutic measures. They cause dilatation of 
the cutaneous capillaries, diminish blood-pressure, and reduce 
nervous excitability. The hot bath is also a method for restor- 
ing warmth to the body in certain cases of shock, or to remove 
the immediate effects of injurious exposure to low temperature. 

The so-called Russian and Turkish baths, so popular in the 
larger cities of this country, are modifications of vapor- and hot- 
air baths, or rather combinations of these with cold baths. The 
Turkish bath is especially to be recommended for its depurative 
and invigorating effects. 

Cold baths are used not merely for their cleansing effects, 
but principally for their stimulating effects upon the system. 
When first plunging into a cold bath there is usually a moment- 
ary shock; the respiration is gasping, and the pulse is increased 
in frequency. These symptoms disappear in a few moments, 
however, and reaction follows. To a healthy person a cold bath 
is a delightful general stimulant, removing the sense of fatigue 
after physical exertion and causing an extremely refreshing 
sensation throughout the body. 

(293) 



294 TEXT-BOOK OF HYGIENE. 

As a therapeutic measure, the cold bath has a wide field 
of usefulness. For the reduction of the bodily temperature in 
fevers and inflammatory diseases, and especially in heat-stroke, 
it is more prompt and effective than any other agent at the com- 
mand of the physician. 

Sea-Bathing. — The most stimulating form of the cold bath 
is doubtless the salt-water bath as taken at the sea-shore. The 
revulsive effect of the impact of the waves and breakers upon 
the skin and the stimulation due to the saline constituents of 
the sea- water heighten the invigorating effects of the simple cold 
bath. The beneficial results of sea-bathing are, however, not 
entirely due to the bath, but are to a great degree dependent 
upon the bracing air of the sea-shore, absence of the care and 
anxieties of business, and the temporary change in food and 
habits that a residence at the sea-side involves. Nevertheless, 
salt-water baths are more stimulant to the skin than those of 
simple water, and part of the good effects of sea-bathing can 
often be obtained from a salt-water bath taken at home. The 
following mixture of salts dissolved in about 125 litres of water 
for one bath makes a fairly good substitute for a sea-bath : — 

Take of Chloride of sodium (common salt), . . .4 kilogrammes. 
Sulphate of sodium (Glauber's salt), . . . 2 " 

Chloride of calcium, ^kilogramme. 

Chloride of magnesium, 1£ kilogrammes. 

There is a prevalent popular belief that it is extremely dan- 
gerous to enter a cold bath when heated or perspiring. The 
author is of the opinion that this belief is erroneous. The stim- 
ulant and bracing effects of the cold bath are most manifest if it 
be taken while the individual is very warm or bathed in perspira- 
tion. Several years ago the author made a series of observations 
upon himself to determine the effects of the cold bath when 
the body was very warm. Every afternoon a free perspiration 
was provoked by a brisk walk of about 2 kilometres in the sun. 
As soon as the clothing could be cast off, and while the body 
was still freely perspiring, a plunge was taken into a fresh-water 
bath of about 15.5° C. (60° F.). No ill results followed; on 



RULES FOR BATHING. 295 

the contrary, the sensation immediately following the bath, and 
for six or eight hours afterward, was exceedingly pleasant. The 
health remained perfect, and the weight decidedly increased 
during the two months the practice was continued. There is 
probably no danger to a healthy person in this practice, but it is 
considered advisable to immerse the head first (" take a header "), 
to avoid increasing the blood-pressure in the brain too greatly, 
which might result if the body were gradually immersed from 
the feet upward. 

RULES FOR BATHING. 

The following series of rules have been issued by the 
English Royal Humane Society, and are all worth observing by 
bathers: "Avoid bathing within two hours after a meal. Avoid 
bathing when exhausted by fatigue or from any other cause. 
Avoid bathing when the body is cooling after perspiration. 
Avoid bathing altogether in the open air, if, after having been 
a short time in the water, there is a sense of chilliness, with 
numbness of the hands and feet; but bathe when the body is 
warm, provided no time is lost in getting into the water. Avoid 
chilling the body by sitting or standing undressed on the banks 
or in boats, after having been in the water. Avoid remaining 
too Ions: in the water, but leave the water immediatelv if there 
is the slightest feeling of chilliness. The vigorous and strong 
may bathe early in the morning on an empty stomach. The 
young, and those who are weak, had better bathe two or three 
hours after a meal ; the best time for such is from two to three 
hours after breakfast. Those who are subject to giddiness or 
faintness, or suffer from palpitation or other sense of discomfort 
at the heart, should not bathe without first consulting their 
medical adviser." 

To these instructions may properly be added that a warm 
or hot bath should be avoided, if the person is liable to ex- 
posure to cold within a few hours after the bath; that women 
should, as a rule, not take a cold bath while menstruating, or 
during the last two months of pregnancy; and that persons 



296 TEXT-BOOK OF HYGIENE. 

suffering from organic heart disease should especially avoid surf- 
bathing. 

After bathing the body should be thoroughly dried with 
soft towels, otherwise eczematous eruptions are liable to follow 
in the parts subject to friction from opposing surfaces of the 
skin, as in the groins, the perineum and inner surface of the 
thighs, the armpits, or the under surface of the breasts in 
women in whom these organs are large and pendant. 

Friction of the skin with a coarse towel, or so-called 
"flesh-brush," is a popular practice, but is not to be universally 
commended. The hyperemia of the surface thus produced 
may sometimes induce cutaneous diseases (erythema, eczema, 
psoriasis) in those predisposed. 

DANGERS OF COLD BATHING. 

One of the most serious dangers of cold bathing, but which 
is not sufficiently appreciated, is the tendency to nausea and 
vomiting if the stomach contains much food. There can be no 
doubt that many of the cases that are called " cramp," and which 
frequently result in drowning, are due to this cause. 1 

Cramps of the various muscles sometimes occur, rendering 
the bather helpless, and if in deep water he is liable to drown 
before assistance can reach him. 

HOW TO RESTORE THE APPARENTLY DROWNED. 

In drowning death takes place by asphyxia. The respira- 
tion is arrested by the submersion of the head, the carbonized 
blood gradually poisons the system, and the heart ceases to beat. 
So long as the heart will react to its appropriate stimulus the 
personmay be restored to life. The first thing to do, therefore, 
after a recently-drowned person is taken out of the water, is to 
attempt to re-establish the arrested respiration. Several methods 
are in use for this purpose. Sylvester's is one of the simplest. 
It is as follows : — 

1 So far as the author is aware, Dr. John Morris, of Baltimore, first called especial atten- 
tion to this source of danger. 



HOW TO RESTORE THE APPARENTLY DROWNED. 297 

The body being . placed on the back (either on a flat sur- 
face or, better, on a plane inclined a little from the feet upward), 
a firm cushion or similar support (a coat rolled up will answer) 
should be placed under the shoulders, the head being kept in a 
line with the trunk. The tongue should be drawn forward to 
raise the epiglottis and uncover the windpipe. The arms should 
be grasped just above the elbows and drawn upward until they 
nearly meet above the head, and then at once lowered and re- 
placed at the side. This should be immediately followed by 
pressure with both hands upon the belly, just below the breast- 
bone. The process is to be repeated fifteen to eighteen times a 
minute. 

Several years since the Michigan State Board of Health 
published a method which is comprehensive, effective, easily 
understood, and readily carried out. This method has also been 
adopted by the United States Life-Saving Service. The follow- 
ing are the details of the Michigan method: — 

Rule 1. — Remove all the obstructions to breathing. In- 
stantly loosen or cut apart all neck- and waist- bands ; turn the 
patient on his face, with the head down hill ; stand astride the 
hips with your face toward his head, and, locking your fingers 
together under his belly, raise the body as high as you can with- 
out lifting the forehead off the ground, and give the body a 
smart jerk to remove mucus from the throat and water from the 
windpipe, hold the body suspended long enough to slowly count 
one — tico — three — four — -five, repeating the jerk more gently 
two or three times. 

Rule 2. — Place the patient on the ground face downward, 
and, maintaining all the while your position astride the body, 
grasp the points of the shoulders by the clothing ; or, if the body is 
naked, thrust your fingers into the armpits, clasping your thumbs 
over the points of the shoulders, and raise the chest as high as 
you can without lifting the head quite off the ground, and hold 
it long enough to slowly count one — two — three. Replace him 
on the ground with his forehead on his flexed arm, the neck 



298 TEXT-BOOK OF HYGIENE. 

straightened out, and the mouth and nose free ; place your 
elbows against [the inner surface of] your knees and your hands 
upon the sides of his chest over the lower ribs, and press down- 
ward and inward with increasing force long enough to slowly 
count one — two. Then suddenly let go, grasp the shoulders as 
before, and raise the chest ; then press upon the ribs, etc. These 
alternate movements should be repeated ten or fifteen times a 
minute for an hour, at least, unless breathing is restored sooner. 
Use the same regularity as in natural breathing. 

Bide 3. — After breathing has commenced restore the 
animal heat. Wrap him in warm blankets, apply bottles of 
hot water, hot bricks, or anything to restore heat. Warm the 
head nearly as fast as the body lest convulsions come on. Rub- 
bing the body with warm cloths or the hands and slapping the 
fleshy parts may assist to restore warmth and the breathing also. 

If the patient can surely swallow, give hot coffee, tea, milk, 
or a little hot sling. Give spirits sparingly, lest they produce 
depression. 

Place the patient in a warm bed, and give him plenty of 
fresh air. Keep him quiet. 

Beware ! Avoid delay. A moment may turn the scale for 
life or death. Dry ground, shelter, warmth, stimulants, etc., at 
this moment are nothing — artificial breathing is everything — is 
the one remedy — all others are secondary. Do not stop to re- 
move wet clothing. Precious time is wasted, and the patient 
may be fatally chilled by exposure of the naked body, even in 
summer. Give all your attention and efforts to restore breath- 
ing by forcing air into, and out of, the lungs. If the breathing 
has just ceased, a smart slap on the face or a vigorous twist 
of the hair will sometimes start it' again, and may be tried inci- 
dentally. Before natural breathing is fully restored, do not let 
the patient lie on his back unless some person holds the tongue 
forward. The tongue by falling back may close the windpipe 
and cause fatal choking. 

Do not give up too soon ; you are working for life. Any 



PUBLIC BATHS. 299 

time within two hours you may be on the very threshold of 
success without there being any sign of it. 1 

PUBLIC BATHS. 

In all large cities and towns provision should be made for 
free public baths, conducted under official supervision, and for 
the especial use and benefit of the poorer classes. General 
cleanliness is not merely a factor in the preservation of the 
public health, but there is good reason to believe that the cause 
of good order and decency would likewise be promoted by 
furnishing the public the means of easily and cheaply keeping 
clean. Several of the larger cities in the country have estab- 
lished public baths upon a limited scale, and these have been 
very popular and have doubtless been of great benefit. The 
author has shown 2 that about five-sixths of the inhabitants of 
the large cities in the United States have no facilities for bathing 
except such as are afforded by a pail of water and sponge, or 
in summer the proximity of some body of water easily 
accessible. The most economical and best form of bath for 
public use would doubtless be the needle or rain bath recom- 
mended by the author in the paper referred to. Mr. W. P. 
Gerhard has also recently strongly advocated this form of bath. 

1 Report of Michigan State Board of Health, 1874, pp. 91-99. 

2 Address in State Medicine, Journal American Medical Association, July 2, 1887. 



QUESTIONS TO CHAPTER XIV. 

Baths and Bathing. 

What is the most important object of bathing? For what other 
purposes may baths be taken? AVhat are the respective temperatures 
of so-called cold, tepid, warm, and hot baths ? What are the physiologi- 
cal effects of the last three ? In what surgical emergencies may the hot 
bath be used ? For what are cold baths used ? What are their physio- 
logical effects ? How may the cold bath be used therapeutically ? 

What is the most stimulating form of cold bath ? To what are its 
beneficial effects due ? How may a salt-water bath be prepared at home ? 
Is there any danger to the healthy in cold bathing while the body is per- 
spiring freely? What precaution should be taken before entering a cold 
bath ? What rules may be laid down for bathing in the open air ? 
When is the best time for bathing ? Who should not bathe without pre- 
vious medical advice? When should hot baths not be taken? What 
should follow all baths ? 

What is one of the most serious dangers of cold bathing ? How 
does death take place in drowning ? What is the indication that one 
apparently drowned ma} 7 still be restored to life ? Describe Sylvester's 
method of artificial respiration. What is the method adopted by the 
United States Life-Saving Service ? What is essential after breathing 
has been re-established? How should spirits be given? How long 
should efforts to restore respiration be continued ? What is to be 
avoided ? 

What are some of the arguments in favor of public baths in large 

cities ? 

What is the most economical form of bath for public use ? 



(300) 



CHAPTER XV. 

Clothing. 

The primary object of clothing is the protection of the 
body against the injurious influences of heat, cold, and moist- 
ure. Secondarily, the moral sense of civilized communities 
demands that the nude human body shall not be exposed in 
public. Hence, there are moral as well as sanitary reasons for 
the wearing of clothing ; only the latter can be considered in 
this place. 

Bodies radiate or absorb heat accordingly as they are sur- 
rounded by a medium having a lower or higher temperature 
than themselves. In order, therefore, to avoid chilling of the 
human body, if exposed to a temperature below 37° C. (98° F.), 
clothing must be worn to prevent or retard radiation of the 
body-heat. Exposure of the unprotected body to a low tem- 
perature would not merely cause chilling of the surface, owing 
to the rapid loss of heat, but would incidentally produce con- 
gestion of internal organs by causing constriction of the super- 
ficial capillaries. 

Clothing is also worn as a protection against great heat. 
The head, especially, needs protection from the sun's rays. 

CLOTHING MATERIALS. 

The materials from which clothing is made are, princi- 
pally, cotton, linen, wool, silk, and the skins of animals. Of 
these, probably the most universally used is cotton. It is cheap, 
durable, does not shrink when wet, absorbs little water, and 
conducts heat readily. It is therefore especially valuable for 
summer garments, allowing rapid dissipation of the body-heat 
and evaporation of the perspiration. 

Linen conducts heat even better than cotton, and is for 

(301) 



302 TEXT-BOOK OF HYGIENE. 

this reason largely used for summer clothing. Its principal 
advantage over cotton is that it is more durable and less harsh 
to the skin. 

Wool absorbs water readily and is a bad conductor of heat. 
It is therefore valuable as a winter garment, retarding radiation 
from the body. Woolen undergarments should be worn at all 
seasons, in order to prevent too rapid changes of the surface, 
and so invoking diseases depending upon chilling of the body. 
Clothing of pure wool (flannels) is liable to irritate the skin 
of some persons. A mixture of wool and cotton, known as 
" Saxony wool," is softer and less irritating, and makes a serv- 
iceable substitute for pure wool. 

Silk is often used for undergarments. It is light, soft, and 
a bad conductor of heat. 

The skins of animals, with the fur on, are often used for 
outside clothing. They furnish great protection against severe 
cold. The skin is impermeable to wind and rain, while the 
thick, pilous covering of fur retards to a very great degree the 
radiation of heat. In British America, the Northwestern 
States and Territories, and in the Arctic regions, the use of skin 
clothing is necessary for comfort. 

As a protection against moisture (rain and snow) rubber 
cloth is used for overcoats, etc. While it serves effectually in 
keeping out the rain, it prevents evaporation of the perspiration, 
increasing the liability to chill, and rendering the person wear- 
ing it very uncomfortable, except in cold weather. 

Leather is used almost exclusively in the manufacture of 
foot-wear. It is sometimes used, however, for other articles of 
clothing, such as coats, trowsers, etc. It furnishes most effective 
protection against cold. 

The color of the clothing is of great importance. Ex- 
posed to the sun, white wool or silk absorb very little more 
heat than linen or cotton, but the same material, of different 
colors, when exposed to the sun's rays, exhibits marked differ- 
ences in absorptive capacity. The following table shows the 



CLOTHING. 



303 



100 heat units. 


102 " 


u 


140 " 


u 


155 " 


it 


165 " 


it 


168 " 


a 


198 " 


a 


208 " 


a 



results of some experiments of Pettenkofer. The material used 
was cotton shirting of the colors named : — 

White absorbed .... 
Light Sulphur Yellow absorbed 
Dark Yellow absorbed 
Light Green absorbed 
Turkey Red absorbed 
Dark Green absorbed 
Light Blue absorbed . 
Black absorbed . 

When protected from the sun's rays, however, the material 
becomes important and the color is of little consequence. Wool, 
being a bad conductor of heat, retards radiation from the body, 
and is hence the best material for winter clothing. 

Gases and vapors, probably also disease-germs, are ab- 
sorbed by clothing, and may be thus conveyed from place to 
place. It has been found that woolen clothing possesses this 
power of absorption to a much greater degree than linen or 
cotton. The bad odor of a crowded room or of tobacco-smoke 
frequently clings to woolen garments for days, although they 
may be exposed constantly to the air during the interval. It 
would be advisable, therefore, that physicians attending infec- 
tious diseases, hospital attendants and nurses, should wear linen 
or cotton clothing instead of woolen. 

Clothing should be made to fit properly. It should not 
restrain muscular movements, obstruct the circulation, or com- 
press organs. Hence, corsets, belts, and garters are to be con- 
demned. It is a fact of common observation that moderately 
loose clothing is warmer than close-fitting. 

Especial attention should be given to the shape and fitting 
of foot-wear. Boots and shoes are usually made with little 
regard to the physiological anatomy of the foot, and as a result 
the feet of most Americans are deformed, beauty and usefulness 
being in a great degree sacrificed to the Moloch of fashion. 1 



1 See a practical paper by Dr. Benj. Lee, A Shoe That Will Not Pinch, in Sanitarian for 
June, 1884, p. 493. 



304 TEXT-BOOK OF HYGIENE. 

Dyes used for coloring fabrics are sometimes poisonous. 
The author has repeatedly seen troublesome eruptions, and even 
ulcerations of the legs, from wearing stockings dyed with aniline 
compounds. 

By appropriate treatment clothing can be made non- 
inflammable. Tungstate and phosphate of soda are used to 
reduce the inflammability of fabrics. The addition of 20 per 
cent, of tungstate of soda and 3 per cent, of phosphate of soda 
to the starch-sizing used for stiffening linen is effective. The 
material is not injured by it, and a smooth surface and polish 
can be obtained under the hot iron. Prof. Kedzie has recom- 
mended borax for the same purpose. He says : " The simplest 
and easiest way to make your cotton and linen fabrics safe from 
taking fire is to dissolve a heaped teaspoonful of powdered borax 
in \ pint of starch solution. It does not injure the fabric, 
imparts no disagreeable odor, and interferes in no way with the 
subsequent washing of the goods. It does not prevent the 
formation of a smooth and polished surface in the process of 
ironing. Borax can be found in every village, and is within 
the reach of all. It is a cheap salt, and its use for this purpose 
is very simple." 1 

[The following works may also be studied to advantage: — 
Hammond, Hygiene, p. 579. — L. Meyer, Kleidung, in Realencyclo- 

pa?die d. ges. Heilk., Bd. VII, p. 446. — Van Harlingen, Care of the Person, 

in Buck's Hygiene and Public Health, vol. i.] 

1 Michigan State Board of Health, p. 181. 1880. 



QUESTIONS TO CHAPTER XT. 

Clothing. 

What is the primary object of clothing? What are some of the 
secondaiy objects? What are the probable results of exposing the 
unprotected body to low temperature ? What part of the body needs 
special protection against heat ? 

What are the principal materials from which clothing is made? 
Which of these is most universally used ? Why ? In what respect is 
linen superior to cotton ? Why are cotton and linen not suited for winter 
wear or cold climates ? Why are silk and wool better for such uses ? 
Why should wool be worn next the skin? What gives silk its value ? 
Why are furs so warm? What are some of the objections to the use of 
rubber clothing ? For what is leather chiefly used ? 

Of what importance is the color of the clothing? What colors 
absorb least and what ones most heat? If protected from the sun's rays, 
which is the most important in the absorption of heat, material or color ? 

What deleterious or harmful matters are absorbed or cling to cloth- 
ing ? What kinds of clothing have the greatest power of absorption ? 
What precautions should those attending cases of infectious diseases 
observe ? 

Why should clothing fit properly ? What parts of the clothing 
should not be too tight ? What disturbances may result from the wear- 
ing of clothing that is too tight ? How may improperly-dyed clothing 
create trouble ? How may clothing be rendered practically non-inflam- 
mable ? 



ao 



(305) 



CHAPTER XVI. 

Disposal of the Dead. 

When life is extinct in the animal body decomposition 
begins. This may be either putrefactive or non-putrefactive. 
The difference between the two processes has been explained by 
Liebig. In putrefaction of organic matters only the elements 
of water take part in the formation of the new compounds which 
result, while in non-putrefactive decomposition or decay the 
oxygen of the air plays an important part. Putrefaction can go 
on under water, while decay can only take place when the 
supply of free oxygen is abundant. 

The prompt removal of the bodies of the dead from the 
immediate vicinity of the living is a matter of prime sanitary 
importance. If death results from a contagious or an infectious 
disease, the necessity for the removal of the corpse is evident. 
But, even where there is no danger of propagation of infectious 
disease, the products of putrefaction and decay may give rise to 
serious derangements of health if allowed to pollute the air. 

The chief methods of disposal of the dead are burial in the 
earth, entombment in vaults, and cremation. 

INTERMENT. 

The most common method of sepulture is burial in the 
earth. The corpse is usually inclosed in a case (coffin) of wood 
or metal, and buried from 1 to 2 metres deep. Here decom- 
position sets in, which is at first putrefactive and later on non- 
putrefactive. In the course of several years, from five to ten, 
the entire body, with the exception of the bones, has usually 
disappeared and become converted into a dry mold. 

The soil of a burial-ground should be dry and porous, so 

(307) 



308 TEXT-BOOK OF HYGIENE. 

as to be easily permeated by the air. In a sandy or gravelly 
soil the decay of a corpse is much more rapid than in a moist, 
clayey soil. In the latter the bodies more readily undergo 
putrefaction, or become converted into a substance termed adi- 
pocere. It has been calculated that in a gravelly soil the decay 
of a corpse advances as much in one year as it would in sand in 
one and two-thirds, and in clay in two to two and one-third 
years. The decay of the dead bodies is principally (if not 
entirely) dependent upon the presence of living vegetable organ- 
isms. If the access of free oxygen is prevented, the bacteria 
of putrefaction will thrive and cause putridity. If, however, 
the soil is loose, porous, and easily permeable by the air, the 
bacteria of decay will be present and produce their charac- 
teristic effects. 

The barometric pressure seems to affect the decomposition 
of dead bodies. For example, at the refuge of St. Bernard, in 
the high Alps, the bodies of those dying are not buried, but 
exposed to the air, where they undergo a drying, shrinking, and 
mummification instead of putrefaction or decay. 

Alternate saturation and drying of the soil promotes the 
rapidity of decay. 

Certain occupations are said to produce changes in the 
tissues which resist decay. Thus, tanners are supposed to resist 
the final changes of the tissues longer than persons of other 
occupations. Shakespeare makes the grave-digger in Hamlet 
say: "A tanner will last you nine years." The corpses of those 
poisoned by phosphorus, arsenic, sulphuric acid, or corrosive 
sublimate also decay more slowly than those of cases of infectious 
diseases. 

All the tissues may be converted into adipocere, but in the 
large majority of cases only the fat and connective tissue undergo 
this change. 

SUPPOSED DANGERS OF BURIAL-GROUNDS. 

Popular sanitary literature teems with supposed instances 
of the injurious influences of cemeteries upon the health of 



SUPPOSED DANGERS OF BURIAL-GROUNDS. 309 

persons living in their vicinity. An unprejudiced consideration 
of the subject shows, however, that there is no trustworthy evi- 
dence that any of the gases exhaled by decaying or putrefying 
bodies are injurious to health. The air of closed burial-vaults 
may be dangerous from the large proportion of carbon dioxide 
contained in it, but the other gaseous products of decomposition 
have no deleterious effects. The dangers to health from the 
proximity of cemeteries are doubtless very much exaggerated. 
Pettenkofer and Erismann have shown that a single large privy- 
vault, containing about 17 cubic metres of excrement, gives off 
nearly as large an amount of putrefactive gases in the course 
of one year as is exhaled by a burial-ground containing 556 
decomposing corpses in ten years. 

Where bodies are properly buried, and the ground is not 
overcharged by corpses, it is not probable that infectious diseases 
are propagated from interred bodies. There are no facts on 
record which show that such an event has occurred. 

The dangers of pollution of water by cemeteries have also 
been much overestimated. The purifying power of soil-strata, 
through which the water is compelled to percolate before reach- 
ing the well after becoming charged with the products of decom- 
position, is in most cases sufficient to remove all deleterious 
matters. 

Cemeteries should not be located within a city, but must 
be easily accessible. The soil should be dry gravel or sand, 
with a low ground-water level. The graves need not be deeper 
than 1^ metres to the top of the coffin. 

ENTOMBMENT IN VAULTS. 

Burial-vaults in churches or in the open air should be 
discountenanced. The gases of decomposition are given off 
directly to the air without the modifying power of the soil, and 
often constitute a nuisance, even if not deleterious to health. 
Entombment in vaults or crypts has not a single favorable 
circumstance to recommend it. 



310 TEXT-BOOK OF HYGIENE. 

CREMATION. 

Within recent years the rapid incineration of the dead in 
properly-constructed furnaces has been frequently recommended. 
In the United States a cremation furnace was built several years 
ago at Washington, Pa., by the late Dr. J. C. LeMoine. Among 
the remains of those cremated were those of the late Dr. Samuel 
D. Gross, the distinguished surgeon. The practice has not 
gained very many adherents, however, although cremation 
societies have been organized and furnaces built in several of 
the cities throughout the country. Aside from the objections 
urged by the more conservative classes, who desire to adhere to 
the time-honored custom of interment, serious legal objections 
have been brought forward. In cases where poisoning is 
suspected some time after death, the cremation furnace would 
have destroyed every evidence of crime, and conviction of a 
criminal poisoner could not be obtained. 

The real advantages of cremation, such as rapid destruction 
of a corpse, economy of space in keeping the remains, and 
avoidance of pollution of the soil by decaying bodies, and pos- 
sible pollution of air and water, are more than counterbalanced 
by the expense and the medico-legal objection mentioned. From 
a sanitary point of view, cremation is not necessary in this 
country. A proper regulation of cemeteries will prevent any 
possible dangers to the living from pollution of the air, soil, or 
water by the decaying remains of human beings. 

INTERMENT ON THE BATTLE-FIELD. 

After battles, the disposal of the bodies of the slain is 
often a serious problem. Naegeli proposes the following method 
of interment : After selecting the place of burial, the sod and 
layer of humus are removed from a sufficiently large surface and 
thrown to one side. The corpses are then laid upon the denuded 
place, and the layers of corpses separated by sand, gravel, or 
fine brush-wood. A trench is then dug around the pile of dead 
and the soil gained is thrown over the corpses until they are 



INTERMENT ON THE BATTLE-FIELD. 311 

covered to a depth of 1 metre, when the humus and sod are 
placed over the whole. This furnishes a dry grave in which 
decay rapidly takes the place of putrefaction, and the corpses 
soon molder away. The same procedure may be followed in 
cases of epidemics where the number of deaths is too great to 
properly bury them in single graves. 



QUESTIONS TO CHAPTER XYI. 

Disposal of the Dead. 

What is the difference between putrefactive and non-putrefactive 
decomposition ? Why must the dead be removed from the living? What 
are the chief methods of disposal of the dead? Which is the most 
common ? 

Why should the soil of burial-grounds be dry and porous ? Upon 
what is the decay of dead bodies dependent ? What is the usual length 
of time required for the decay of a human body ? What may affect the 
length of this period ? What changes other than decay may the body 
undergo ? 

Is there any evidence that the air from cemeteries is dangerous to 
health ? In what way may the air from a closed burial-vault be detri- 
mental? Is it probable that infectious disease-germs are disseminated 
from dead bodies ? Is the pollution of water b}^ cemeteries probable ? 
What agents serve to prevent this ? Where should cemeteries be located, 
however ? Why should entombment in vaults be discountenanced ? 

What are the advantages of cremation? What are the objections 
to it ? Is it necessary, from a sanitary point of view, in this country ? 

How may the bodies of the dead be interred after battles, or in case 
of very fatal epidemics ? What are the advantages of this method ? 



(312) 



CHAPTER XVII. 

The Germ Theory of Disease. 

The ruling doctrine in the pathology of the present day is 
the germ theory of disease. Based npon the doctrine of omne 
vivum ex vivo, and supported by strong experimental and clinical 
evidence, it is accepted by the great majority of physicians. Its 
advocates claim that the large class of diseases known as con- 
tagious or infectious are all due to the presence in the blood or 
tissues of minute organisms, either animal or vegetable. Many 
other diseases, not at present included in the above class by 
general pathologists, are also believed, by the adherents of the 
germ theory, to be caused in the same way. The following con- 
stitutes a brief review of the most prominent facts in the history 
of the doctrine : — 

The doctrine of the vital nature of the contagium of dis- 
ease — the contagium animatum of the older writers — was held 
in a vague way by many of the physicians of the past, but it was 
not until the latter part of the last century that the theory took 
definite shape. In the works of Hufeland, Kircher, and Linne 
the idea is expressed with more or less directness that the propa- 
gation of infectious diseases depends upon the implantation of 
minute independent organisms into or upon the affected indi- 
vidual. This hypothesis was. however, first clearly enunciated 
and defended with great force by Henle in 1810. Three years 
earlier, Cagniard de'la Tour and Schwann had established a 
rational basis for the theory by their observations upon the yeast- 
plant and its relation to fermentation. In 1835 Bassi had dis- 
covered in the bodies of silk -worms affected by muscardine, a 
disease of these insects which proved very destructive, a para- 
site which was soon shown to be the cause of the disease. 
Within the next few years, Tulasne, DeBary, and Kuehn 

(313) 



314 TEXT-BOOK OF HYGIENE. 

proved that certain fungi were the causes of the potato-rot and 
other diseases of plants. Schoenlein, Malmsten, and Gruby, 
between 1840 and 1845, demonstrated that those skin diseases 
of man classed as the tlneoe were due entirely to the action of 
vegetable parasitic organisms. 

Up to this time the germ theory, as now accepted, had 
received no support from experiments. All the diseases claimed 
as parasitic were purely local ; so far as the parasitic nature of 
the general diseases was concerned, all was hypothetical. In 
1849, Guerin Meneville discovered a corpuscular organism in 
the blood of silk-worms affected by the pebrine, which was later 
proven by Pasteur to be the true cause of this destructive dis- 
ease. Pollender, in 1855, and Brauell, in 1857, found numer- 
ous minute rod-like organisms (bacteria) in the blood of animals 
dead from splenic fever. In 1863 Davaine investigated the 
subject more fully, and showed beyond doubt that the little 
organisms discovered by Pollender were the true cause of splenic 
fever, or anthrax. The more recent researches of Robert Koch 
upon the history of these bacteria or bacilli of splenic fever 
have removed all doubt of their etiological significance. 

In 1883 the last-named observer startled the medical world 
by the assertion that consumption or tuberculosis was a disease 
of microbic origin, and dependent upon the presence, in the 
affected tissues, of an organism which he named bacillus tuber- 
culosis. Much controversy arose upon this point, but Koch 
fortified his position so strongly with proofs, both experimental 
and clinical, that it may now be regarded as fully demonstrated. 
Koch has likewise shown (1885) that Asiatic cholera is due to 
a bacterial organism, termed by him the " comma bacillus," 
from its shape. It is generally regarded by bacteriologists, how- 
ever, to belong to the class of organisms known as spirilla, and 
not to the bacilli. Eberth discovered the bacillus which is now 
generally accepted as the cause of typhoid in 1880; Fehleisen, 
the micrococcus of eiysipelas in 1883; Obermeier, the spirillum 
of relapsing fever in 1868; Schutz and Lofrler discovered the 



THE GERM THEORY OF DISEASE. 315 

bacillus of glanders in 1882; Neisser announced the discovery 
of the micrococcus of gonorrhoea in 1879. The bacillus of 
leprosy was discovered by Hansen in 1879. The micro-organ- 
isms of malaria (oscillaria malarise), which are believed to be 
animal organisms, were discovered by Laveran in 1881. This 
organism is different from the bacillus malarias of Klebs and 
Tommasi-Crudeli, which possesses no pathological significance. 
Pneumonia may also be regarded as a microbic disease, since 
Sternberg, Weichselbaum, and Frankel have shown the constant 
presence of the micrococcus Pasteurii in the sputa in that 
disease. In 1887 Nicolaier and Rosenbach proved that tetanus 
is due to a bacillus. 

The careful observations and researches of the investigators 
mentioned, as well as of many others who have worked earn- 
estly in this field, have established the germ theory of disease 
upon a secure foundation. For the diseases mentioned the 
parasitic origin may be accepted as fully proven. For a number 
of others, among which may be mentioned small-pox, yellow fever, 
diphtheria, scarlet fever, typhus fever, measles, hydrophobia, etc., 
the etiological connection between the disease and certain hypo- 
thetical organisms not yet discovered appears probable. 

In connection with the germ theory there has arisen of late 
a very important question in its bearing upon preventive medi- 
cine. This is the value of the so-called protective inoculations 
against infectious diseases. The protective influence of vacci- 
nation against small-pox is firmly established by indubitable 
evidence. Within the last three or four years a procedure in- 
troduced by Pasteur to protect animals against certain fatal in- 
fectious diseases, such as splenic fever, fowl-cholera, and rabies, 
has claimed much attention. Pasteur's observations were first 
made upon the disease termed chicken-cholera. He found that 
the blood of the dead fowls, or of those attacked by the disease, 
swarmed with bacteria. Inoculation of healthy fowls with this 
diseased blood, or with the bacteria alone, carefully freed from 
all animal fluids, produced the same disease. The bacteria 
were therefore assumed to be the cause of the disease. The 



316 TEXT-BOOK OF HYGIENE. 

investigator then took a quantity of these bacteria and " culti- 
vated " them through a number of generations, using sterilized 
chicken-broth as a culture medium. Fowls inoculated with the 
result of the last cultivation were still attacked by the same 
symptoms, but in a very mild degree, and almost uniformly 
recovered from the disease. On subsequent inoculation with 
infected blood no effect was produced upon the " vaccinated " 
fowls, while the same blood introduced into fowls not " pro- 
tected " by the previous inoculation produced its customary 
fatal effect. Pasteur and others repeated these experiments 
with the organisms found in the blood in splenic fever and 
obtained similar results. Inoculations made with cultivations 
from the spinal cord of animals suffering from rabies have also 
been claimed as protective against this disease and hydrophobia. 
These protective inoculations have been made upon large num- 
bers of sheep and cattle within the past three years, and with 
very remarkable success. Recently, however, it has been shown 
that the protection afforded by the inoculation is a very tem- 
porary one, and that after a variable but brief interval the pro- 
tected animals are again liable to be fatally attacked by the 
disease. The opinion seems to be justified that cultivation pro- 
duces only a temporary degeneration of the bacteria, which 
rapidly disappears when the organisms are again brought in 
relation with their proper nutritive fluid. The " protective in- 
oculations " produce a mild attack of the disease, which is for a 
time a bar against a second attack ; but the effect soon wears off, 
leaving the animal in its pristine condition of receptivity toward 
the infective material. 

[The following works on this subject are recommended to 
the student : — 

Sternberg and Magnin, The Bacteria; second edition. — Fluegge, 
Fermente und Mikroparasiten, in von Pettenkoffer und Ziemssen's 
Handbuch d. Hygiene.] 



QUESTIONS TO CHAPTER XYII. 

The Germ Theory of Disease. 

What is meant by the germ theoiy of disease ? When did this doc- 
trine first take definite shape ? When was it first clearly enunciated, and 
by whom? What basis was there then for it? What subsequent evi- 
dence soon developed? What was the first evidence of the parasitic 
nature of general diseases ? Who discovered and who first demonstrated 
the true cause of anthrax ? Who proved tuberculosis to be of microbic 
origin? When? What other diseases are now known to be caused by 
specific micro-organisms ? What others are probably due to a like 
cause ? 

What effect has the establishing of the germ theory upon preventive 
medicine ? What is meant hy protective inoculation ? What evidence 
is there that this is possible How do disease germs produce their char- 
acteristic effects upon the system ? How may the inoculating material 
be prepared ? What are some of the theories regarding the method by 
which susceptible animals or persons are rendered immune ? Does the 
protection by inoculation seem to be permanent ? 



(317) 



CHAPTER XVin. 

Contagion and Infection. 

The adjectives "contagious" and "infectious" are used to 
designate certain diseases which are propagated by immediate 
contact, or through the intervention of some other medium, from 
the sick to the healthy. The matters in which reside the mor- 
bific power are now believed by many to be vegetable organisms, 
but not a few pathologists hold to the view that the real con- 
tagia, or disease-bearing agents, are modified animal cells or 
abnormal fluids. 

The differentiation between contagion and infection is not 
easy. Many of the diseases commonly called contagious are 
also infectious ; that is, they are propagated not merely by direct 
contact, but also by air, water, or food which may have become 
infected with the morbific agents. Syphilis, for example, may 
be regarded as simply a contagious disease ; at the present day, 
at least, we cannot conceive syphilis to be propagated by breath- 
ing infected air or drinking water contaminated with the poison 
of syphilis. Cholera, typhoid, and yellow fevers, on the other 
hand, are examples of infectious diseases, neither of them being 
directly contagious, but conveyed from sick to well through the 
medium of contaminated air, water, or food. Between these 
two stand small-pox and typhus fever (and perhaps the other 
exanthemata), which are not merely contagious, but infectious 
also. 

There is still a third class of acute diseases not properly 
included in either of the classes mentioned. This is the class of 
miasmatic diseases, of which malarial fevers are the type. Ac- 
cording to recent observations, pneumonia and epidemic influenza 
ought, perhaps, to come in this class. 

The contagious and infectious diseases are of particular 

(319) 



320 TEXT-BOOK OF HYGIENE. 

interest to sanitarians, because it is believed that by judicious 
carrying out of sanitary measures they can be prevented. Hence 
they are sometimes termed preventable diseases. Another pecu- 
liarity of the infectious diseases is that they usually occur in 
groups of cases. Thus, small-pox, measles, scarlet fever, typhus 
fever, diphtheria, and others of the class do not occur sporadi- 
cally, as it is termed ; that is to say, it rarely happens that only 
one case of small-pox is observed in a locality, unless active 
measures are at once taken to stamp it out. Usually a number 
of cases occur successively, and in most instances the succeeding 
cases can be traced ultimately to the first case. 

Contagious and infectious diseases frequently appear as 
epidemics. Authorities differ as to the proper definition of an 
epidemic; that is, given the population of a place, how many 
cases of an infectious or contagious disease are necessary before 
the disease can be considered epidemic at such place. The 
following formula was given by the New Orleans Medical and 
Surgical Association in response to the query, "Under what cir- 
cumstances is it proper to declare such diseases (diphtheria, 
scarlet fever, measles, small-pox, yellow fever, etc.) epidemic in 
a place V' The answer given is that the disease should be 
declared epidemic when the number of cases should reach these 
proportions 1 : — 



a population 


of 


100 . . 


5 per cent. 


it a 


it 


500 . . 


4 a a 


u u 


u 


2,000 to 5,000 . 


22^ " thousand. 


u u 


u 


6,000 to 10,000 . 


16 " " 


U it 


u 


20,000 to 50,000 . 


8 " ten thousand, 


it a 


a 


50,000 to 100,000 . 


4 u u u 


u it 


it 


200,000 . 


Y a a <c 



A disease is said to be pandemic when it spreads rapidly 
over a great extent of country, and endemic when it is constantly 
present in a place. Diseases which may be prevalent in certain 
localities, i.e., endemic, not infrequently spread over larger areas 

i Public Health, vol. vi, pp. 416, 417. 



CONTAGION AND INFECTION. 



321 



of country, — overflow their borders, as it were, — and become epi- 
demic or pandemic. Thus cholera, which is endemic in certain 
districts of India, frequently spreads over adjacent territory, and 
at times the epidemic wave, as it has been called, rolls over 
nearly the whole world. Plague, malarial and yellow fevers 
make similar epidemic excursions into other countries, or sec- 
tions of country, at a distance from the places where they are 
endemic. 

Contagious and infectious diseases possess another peculi- 
arity in that a certain time is required after the introduction of 
the poison into the system before the disease manifests itself by 
its typical symptoms. This is called the "stage of incubation," 
and varies for different diseases. The following table shows the 
stage of incubation of a number of such diseases : — 



Table XXIX. 



ON OF INFECTIOUS DISEASES. 



10 


days 


12 


u 


18 


u 


3 


u 


3 


u 


14 


u 


14 


a 


1 to 2 


u 


4 


a 


4 


a 



INCUBAT 

Measles, . 
Small-pox, 
Mumps, . 
Diphtheria, 
Scarlet fever, 
Whooping-cough, 
Typhoid fever, . 
T} T phus fever, . 
Chicken-pox, . 
Eiysipelas, 



The period during which the infectiveness of the patient 
lasts also varies, In some cases it probably depends upon the 
measures taken to prevent the spread of the disease, e.g., disin- 
fection of the patient and his surroundings. 

The London Clinical Society has very recently made public 
a report by one of its committees, which has for several years 
carefully studied the questions of incubation and the duration 
of infection. The conclusions reached do not differ essentially 
from those in the above table, but as they are given somewhat 
more in detail they are here appended : — 

21 



322 TEXT-BOOK OF HYGIENE. 

Diphtheria, two to seven days ; oftenest two. 

Typhoid fever, eight to fourteen days; sometimes twenty- 
three. 

Influenza, one to four days ; oftenest three to four. 

Measles, seven to eighteen days ; oftenest fourteen. 

Mumps, two to three weeks ; oftenest three weeks. 

Rubeola, two to three weeks. 

Scarlet fever, one to seven days ; oftenest two to four. 

Small-pox, nine to fifteen days ; oftenest twelve. 

Further investigations were made with regard to the time 
and duration of the infective period. 

Diphtheria was found to be infective during the period of 
incubation, attack, and convalescence. 

Mumps and rubeola are also infective for three or four days 
before the onset of the parotiditis and appearance of the rash. 

The contagiousness of measles speedily disappears, and 
does not continue in disinfected persons for over three weeks. 

Typhoid fever is infectious from the time of onset until two 
weeks after the fever has gone and convalescence set in. 

As is well known, the contagiousness of scarlet fever varies 
greatly, but is generally continued a very long time — certainly 
until desquamation ceases, and sometimes as long as eight 
weeks. 



QUESTIONS TO CHAPTER XVIII. 

Contagion and Infection. 

What is the difference between a contagious and an infectious dis- 
ease ? Give examples of each. What diseases do not belong to either 
of these classes ? What other names might be given to contagious and 
infectious diseases? How do they usually occur? What are their ex- 
citing causes ? How may they be prevented ? 

What is an epidemic ? When may a disease be declared epidemic 
in a city of 10,000 persons ? When is a disease pandemic ? When en- 
demic? May an endemic disease become epidemic or pandemic? 

What other peculiarities do contagious and infectious diseases pos- 
sess ? What diseases have the longest period of incubation ? What ones 
the shortest ? How does the period of incubation support the germ 
theory ? What other definite period has each of these diseases ? What 
is the usual duration of a case of typhoid fever ? Of scarlet fever ? Of 
measles ? Does this support the germ theory? How long does a typhoid 
patient remain infective ? How long a diphtheria patient ? A scarlet- 
fever patient ? (See chapters on School Hygiene and Quarantine.) Upon 
what does the danger and period of infectiveness depend ? Are these 
diseases all likely to confer immunity against future attacks ? Which 
are most likely to do this ? 



(323) 



CHAPTER XIX. 

History of Epidemic Diseases. 

An important part of the knowledge of the sanitarian is 
that which relates to the history of the great epidemic diseases 
which have at various periods devastated large areas of the in- 
habited world. In this chapter the history of these diseases will 
be briefly traced. Although some of these diseases have nearly 
or quite ceased, a knowledge of their habits and of the causes 
that finally led to their extinction is of great value, for the reason 
that the principles and measures of prevention which were 
effective in times past are the same which must apply at pres- 
ent and in the future. Hence, time spent in looking back over 
the fields traversed and noting victories won will not be wasted. 

The epidemic diseases which will here claim attention are 
the Oriental plague, the sweating sickness, small-pox, Asiatic 
cholera ; typhus, typhoid, scarlet, relapsing, and yellow fevers ; 
diphtheria, dengue, epidemic influenza, and syphilis. In addi- 
tion, some information will be given on certain of the diseases 
of animals transmissible to man. Among these are sheep-pock, 
actinomycosis, bovine tuberculosis (perlsucht), rabies, anthrax 
(milzbrand), and glanders. 

THE ORIENTAL PLAGUE. 

The Oriental plague, bubonic plague, the black death, or 
simply the " plague," or great pestilence, overtopping in its 
fatality all other pestilences, is mentioned by a number of the 
Greek and Latin medical authors. The first account which 
clearly refers only to this disease is given by Procopius. Ac- 
cording to this and other contemporary authors, the disease be- 
gan to spread in the year 542 from Lower Egypt, passing in one 
direction along the coast of Northern Africa, and in the other 

(325) 



326 TEXT-BOOK OF HYGIENE. 

invading Europe by way of Syria and Palestine. In the course 
of the succeeding years this pandemic reached " the limits of the 
inhabited earth," in the language of the writers of the day. The 
disease prevailed about half a century, and produced the greatest 
devastation wherever it appeared. " Cities were devastated, the 
country converted into a desert, and the wild beasts found an 
asylum in the abandoned haunts of man." 1 

The plague is an acute infectious disease, which is char- 
acterized by an affection of the lymphatic system, i.e., inflam- 
mation and swelling of the external and internal lymphatic 
glands. Accessory symptoms are petechial spots upon the skin, 
and haemorrhages from various organs, as the stomach, nose, 
kidneys, rectum, and uterus. Those attacked suffer in varied 
degrees of intensity. In some, a fulminant form occurs which 
carries off the patient within three days ; there is another class 
of cases in which buboes develop, with accompanying fever and 
haemorrhages; and, finally, a light form, rarely fatal, in which 
only the local symptoms are manifested. In the great pan- 
demic of the plague in the fourteenth century cough and bloody 
expectorations were very frequent. In the later epidemics 
haemorrhage from the lungs has been rarely noticed as a symptom. 

About the middle of the fourteenth century the bubonic 
plague made a second incursion into Europe from its home in 
the East. A most graphic description of its ravages is given by 
Boccaccio in the " Decameron." This author states that in 1359, 
" between March and July following, according to authentic 
reckonings, upward of 100,000 souls perished in the city 
(Florence) ; whereas, before that calamity it was not supposed 
to contain so many inhabitants." 

This terrible epidemic was forcibly characterized by its com- 
mon name, " the black death." Hecker estimates that during its 
continuance, from 1347 to 1351, 25,000,000— one-fourth of the 
probable total population of Europe — died. In various cities 
the mortality was — in London, 100,000 ; in Paris, 50,000 ; in 

1 Warnefried, quoted by Hirsch, Hist-Geographische Pathologic, I, p. 350. 



THE ORIENTAL PLAGUE. 327 

Venice, 100,000 ; in Avignon, 60,000 ; in Marseilles, 16,000, in 
one month. It was said that in all England scarcely a tenth 
part of the population escaped death from the disease. 

The moral effects of this great pandemic of the plague were 
hardly less deplorable than the physical. Religious fanaticism 
held full sway throughout Europe, finding its vent in all manner 
of excesses. The so-called Brotherhood of the Cross, otherwise 
known as the Order of Flagellants, which had arisen in the 
thirteenth century, but had been suppressed by the ecclesiastical 
authorities, was revived during the black pestilence, and large 
numbers of these religious enthusiasts roamed through the 
various countries on their great pilgrimages. Their power in- 
creased to such a degree that Church and State were forced to 
combine for their suppression. One consequence of this fanat- 
ical frenzy was the persecution of the Jews. These were accused 
of being the cause of every evil that befell mankind, and many 
were put to death. 

In the fifteenth and sixteenth centuries the plague was 
generally diffused throughout Europe, and in the second third 
of the seventeenth century its final incursion into the Occident 
took place. The great epidemic in London, so graphically de- 
scribed by Defoe, 1 occurred in 1665. In the early part of the 
eighteenth century (1T20) the plague visited Marseilles and 
Toulon ; from 1769 to 1772 it was epidemic in Moldavia, Wal- 
lachia, Poland, and Southern Russia ; near the close of the last, 
and in the beginning of the present century, in Transylvania, 
AVallachia, Southern Russia, and Greece. Very recently, in 
1878 and 1879, and in 1885, the plague threatened a new 
irruption into European territory, being epidemic in the district 
of Astrachan, on the Caspian Sea. At the date of writing 
(August, 1894) it is reported epidemic in certain parts of China. 

Although the bubonic plague has never been observed in 
America, and has spared Europe almost entirely during the present 
century, it still persists in certain countries of Asia and Africa, 
especially in Arabia, Mesopotamia, Persia, and the coast of Tripoli. 

1 Journal of the Plague in London. 



328 TEXT-BOOK OF HYGIENE. 

The older authors ascribed the origin of the plague to 
various real or supposed conditions. Comets, conjunctions of 
the planets, " God's just punishment for our sins," and similar 
causes were advanced to account for the outbreaks. Most of the 
writers of the post-mediaeval and modern epochs ascribed the 
disease to meteorological conditions. Observing the fact that the 
plague never advanced into the torrid zone, and that an epidemic 
generally ended with the advent of hot weather, a high tempera- 
ture was believed to be incompatible with the existence of an 
epidemic, and a cold or temperate climate was considered neces- 
sary to an outbreak of the disease. The exceptions to the rule 
are so numerous, however, that the theory of the climatic or 
meteorological origin of the plague failed of support. The theory 
which ascribed the origin of the epidemics to the influence of 
certain hot and dry winds or a high humidity is also insufficient. 
Certain geological formations have been supposed to furnish 
favorable conditions for the development of the disease. Facts 
show, however, that the disease has prevailed epidemically and 
endemically in various parts of the earth, and of the most diverse 
geological character. A certain elevation above sea-level has 
been held to confer immunity, but recent observations in India 
show that this belief is unfounded, even places at an elevation 
of 10,000 feet above sea-level giving no security against attack. 

There is, however, one point upon which nearly all writers 
who mention the fact at all agree. This is that bad hygienic 
conditions are always present where plague prevails. Nearly all 
observers who have left their impressions on record mention the 
accumulation of filth in the houses and streets, deficient removal 
of excrementitious and other sewage matters, crowding and im- 
perfect ventilation of dwellings as causes favoring the develop- 
ment and spread of the pestilence. All point out the necessity 
of the removal of these evils as the most important prophylactic 
measure to be adopted, and all of them call attention to the fact 
that those classes of the population most exposed to these unfa- 
vorable influences suffer most from the violence of the epidemic. 



THE ORIENTAL PLAGUE. 329 

The later reports of the epidemics in Persia, India, Mesopo- 
tamia, and Russia agree in asserting that nothing seems to have 
promoted the epidemic and endemic prevalence of the plague so 
much as the material wretchedness of the inhabitants of those 
countries. In a collection of papers on the plague, printed by 
a British Parliamentary Commission in 1879, occur these state- 
ments : " The filth is everywhere," says Mr. Rennie, one of the 
reporters, — " in their villages, their houses, and their persons. 
Their dwellings are generally low and ill-ventilated, except 
through their bad construction ; and the advantage of the 
natives in other parts of India, of living in the open air, is lost 
to the villagers of Ghurwal, from the necessity of their crowding 
together for mutual warmth and shelter against the inclemency 
of the weather." Dr. Dickson, reporting on the plague in Irak 
Arabi in 1876, says: " The most palpable and evident of all the 
causes which predispose an individual to an attack of plague 
during an epidemic outbreak is poverty. No other malady shows 
the influence of this factor in so striking a degree ; so much so, 
indeed, that Dr. Cabiadis styles the plague miseries morbis. In 
his experience (1876-77, in Bagdad) he found that the poor 
were seldom spared, the wealthy hardly ever attacked." 1 

The manner of the transmission of the plague is generally 
by prolonged inhalation of an infected atmosphere. Hence, it 
may be termed an infectious disease, although it is not improbable 
that it may be communicated by direct contact both of persons 
and of fomites. It is probably due to a micro-organism, although 
no demonstration of the latter has been furnished up to the 
present time. 

These considerations indicate the measures of prevention 
to be adopted. They consist of a rigid quarantine of persons 
and fomites, prompt and complete isolation of infected individuals 
and localities, and destruction (by fire) or thorough disinfection 
by steam or sulphurous-acid gas of all materials capable of con- 
veying the virus of the disease. 

1 Hirsch, op. cit., p. 370. 



330 TEXT-BOOK OF HYGIENE. 

THE SWEATING SICKNESS. 

This name concisely characterizes an epidemic disease 
which for the first time appeared in the city of London and 
other parts of England in the autumn of 1485. According to 
Lord Bacon, 1 the disease began about the 21st of September 
and lasted until near the end of October. It broke out a second 
time in the summer of 1507; a third time in July, 1518, spread- 
ing in the course of six months throughout England. In May, 
1529, the disease made its appearance again in the latter country, 
spreading thence over a great part of the continent of Europe. 
Another very malignant epidemic broke out in the spring of 
1541, lasting through the summer, and limited in its ravages to 
England. 

With this last outbreak, in 1551, thfs disease disappeared 
entirely in England and has not re-appeared there up to the 
present day. In the beginning of the eighteenth century, how- 
ever, a disease very similar in its symptoms and course broke out 
in Picardy and other districts of Northern France, being confined 
for a number of years to this section of the country. Toward 
the end of the century it spread to the south of France, and 
since that time has appeared epidemically at intervals, 195 dis- 
tinct outbreaks having been observed in the course of 168 years, 
from 1718 to 1887. The disease has frequently appeared in Italy 
since 1755, and in various parts of Germany since 1801. In 
Belgium it has been observed at a few places within the present 
century. 

The disease appeared suddenly, often at night-time. The 
patient was attacked with palpitation of the heart, dyspnoea, 
great anxiety and oppression, and profuse perspiration. A 
miliary eruption often appeared on the skin. In favorable cases 
these symptoms diminished in the course of one or two days, the 
urinary secretion, which had been suppressed, was restored, and 
the perspiration became gradually less free. Recovery ensued 
in from one to two weeks. In grave cases there were, in the 

1 History of Henry VII. 



SMALL-POX. 331 

beginning of the attack, violent headache, delirium, convulsions, 
followed by a comatose condition, from which the patients rarely 
recovered. 

This disease is undoubtedly of a miasmatic, infectious nature, 
as proved by its rapid spread and limitation to certain localities. 
It appears most frequently in the spring and summer, and is 
nearly always observed in marshy or damp localities. Its spread 
is favored by a high temperature and humidity. There is no 
apparent connection between the outbreaks of the sweating 
sickness and overcrowding or other insanitary conditions; in 
fact, it is stated by numerous observers, both old and recent, that 
children, the aged, and generally the poorer classes were remark- 
ably exempt from the disease. The recent epidemic in France, 
in 1887, was investigated by Dr. Brouardel, Chantemesse, and 
other epidemiologists, but no trustworthy conclusions as to the 
nature of the disease have yet been reached. 

Since the first appearance of Asiatic cholera in France, in 
1832, an apparently intimate connection has been observed 
between the occurrence of that disease and outbreaks of sweating 
sickness. A disease strongly resembling the sweating sickness 
has also been observed in India in districts contiguous to places 
where cholera was at the time epidemic. 1 

SMALL-POX. 

The earliest details concerning small-pox are derived from 
certain Chinese records, according to which it appears that this 
disease was known in China upward of 2000 years ago. It was 
also known at a very early period in India. It is believed to 
have been introduced into Europe in the second century by a 
Roman army returning from Asia. It is believed that the Em- 
peror Marcus Aurelius died of small-pox, which prevailed in his 
army at the time of his death. 

The first distinct references to small-pox in medical literature 
occur in the writings of Galen, in the second century. Rhazes, 

1 Murray, Madras Quart. Med. Journ., 1840-41. Quoted in Hirsch, loc. cit., p. 83. 



332 TEXT-BOOK OF HYGIENE. 

in the ninth century, wrote upon the disease, describing it very 
accurately. 

The almost universal susceptibility to small-pox caused 
wide-spread devastation wherever it appeared previous to the 
introduction of vaccination. The statement is made that in 
England, in the last century, about one person in every three 
was badly pock-marked. The mortality from the disease was 
exceedingly great, being, in the latter half of the eighteenth 
century, about 3000 per million of inhabitants annually. 

In India the mortality from small-pox has been exceedingly 
great within the last twenty years. From 1866 to 1869, 140,000 
persons died in the Presidencies of Bombay and Calcutta, having 
a population of about 40,000,000. Several years later, from 
1873 to 1876, 700,000 died from this disease. 

China, Japan, Cochin China, the islands of the China Sea, 
and Corea are frequently ravaged by small-pox. In the latter 
country nearly all the inhabitants are said to bear evidence of 
an attack of the disease. 

The Samoyedes, Ostiaks, and other natives of Eastern Siberia 
have frequently suffered from devastating epidemics. In Kamt- 
chatka the disease was introduced in 1767, and produced 
frightful ravages. Many villages were completely depopulated. 

In Mexico small-pox was introduced by the Spaniards in 
1520. In a short time it carried off over 3,500,000 of the 
natives. In the Marquesas Islands one-fourth of the inhabitants 
have fallen victims to the disease since 1863. 

It was first introduced into the Sandwich Islands in 1853, 
and carried off 8 per cent, of the natives. 

Australia, Tasmania, New Zealand, and the Fejee Archi- 
pelago remain exempt to the present day from small-pox/ It has 
several times been carried to Australia by vessels, but has always 
been promptly checked by the vigilance of the authorities. 

On the Western Hemisphere small-pox was unknown before 
the arrival of the European conquerors. It has been spread by 
the whites or imported African slaves to nearly all the Indian 



SMALL-POX. 333 

tribes of both continents. When it attacks large communities 
unprotected by previous outbreaks of the disease, or by inocula- 
tion or vaccination, its ravages are frightful. The mortality of 
unmodified small-pox is usually between 30 and 40 per cent. 

Small-pox is a highly contagious and infectious disease. 
It is produced by actual contact, by inoculation, and by inhaling 
an atmosphere charged with the poison. In order to cause an 
outbreak two factors are necessary : first, a number of individuals 
susceptible to this disease, and, second, the introduction into the 
body, in some manner, of the virus upon which it depends. 

Small-pox is spread from (1) persons sick with the disease; 
(2) others, not themselves sick or susceptible, but coming in 
contact with the poison; (3) fomites (cotton, wool, etc.), and (4) 
the bodies of persons dead with small-pox. It is also probable 
that the air in the immediate vicinity of a person sick with small- 
pox becomes charged with the poison and able to convey the 
disease. It is at present impossible to fix the distance to which 
this infectiousness of the air extends, but it does not ordinarily 
reach beyond the room in which the patient is confined. 

It is a fact of common observation that the darker races 
are more commonly attacked, and the disease is likewise more 
fatal among them. The mortality among negroes is much larger 
than among other races. 

It is a current belief that small-pox is only contagious after 
the development of the pustules. This is a serious error. It is 
probably contagious in all stages of the disease ; certainly as 
early as the first appearance of the eruption, and probably even 
in the stage of preliminary fever. 

One attack of small-pox usually confers immunity from the 
disease for life. This rule has its exceptions, however, which, if 
not numerous, are yet not infrequent. The author has seen a 
case in which the patient suffered from a third attack of the 
disease. 

The popular belief, that persons suffering from any acute 
or chronic disease are less liable to be attacked by small-pox 



334 TEXT-BOOK OF HYGIENE. 

than those at the time in good health, is erroneous. On the 
contrary, the subjects of chronic disease, such as consumption or 
dyspepsia, are much more liable to succumb to an attack of 
small-pox than persons previously in good health. 

It is true, however, that individuals suffering from some 
other acute infectious disease, like scarlet fever, measles, typhoid 
fever, etc., are generally, though not absolutely, exempt from 
an attack of small-pox during the time they are sick with such 
disease. But if they are exposed, after recovery, to the small- 
pox infection, their liability to an attack is as great as in those 
who have not passed through a similar disease. A number of 
cases have been reported by Curschmann, 1 in which infection 
by small-pox took place on the day in which convalescence from 
typhoid fever was established. 

The author has reported a case 2 in which the patient passed 
through an attack of erysipelas during the incubative stage of 
small-pox. From all the evidence attainable, the incubative stage 
was not prolonged by the intercurrent erysipelas. 

Epidemics of small-pox usually begin in the autumn or 
winter, and lessen in violence as warmer weather approaches. 
The spread of the disease is slow at first, increasing in rapidity 
as the foci of infection multiply. 

When the poison is imported into a community late in the 
spring or during the summer, the increase in the number of 
cases is exceedingly gradual until colder weather sets in. If it 
is introduced during the winter, the disease spreads much more 
rapidly, but decreases, and sometimes almost disappears, during 
the summer. On the return of cold weather, however, the epi- 
demic starts out with a new lease of activity and presents great 
difficulties to its restriction. 

A number of observers, among whom are Coze and Feltz, 
Lugenbuhl, Weigert, Strauss, Garre, and Wolff, claim to have 
discovered specific organisms in the contents of variolous pustules, 
in the blood of patients with the disease, and in vaccine lymph. 

1 Ziemssen's Cyclopaedia, vol. ii. s Medical News, July 7, 1883. 



SMALL-POX. 335 

Expert bacteriologists are, however, not willing to accept the 
evidence hitherto furnished as conclusive. 

Inoculation. — The prevention or restriction of such a uni- 
versal and fatal pestilence as small-pox is a matter of the deepest 
importance. The first attempt to limit its fatality dates from the 
end of the seventeenth century. It became generally known in 
Europe, about the year 1700, that the intentional inoculation of 
variolous matter into healthy individuals induced an attack of 
the disease, which generally ran through its various stages with 
less virulence than when the disease was contracted in the usual 
manner. In 1716 and 1717 two papers were published in the 
" Transactions of the Royal Society of England " giving an ac- 
count of the process of inoculation. The attention of the public 
was especially directed to the matter, however, by the famous 
letter of Lady Mary Wortley Montagu, dated April 1, 1717. This 
letter is as follows 1 : "Apropos of distempers, I am going to tell 
you a thing that will make you wish yourself here. The small- 
pox, so fatal and so general amongst us, is here entirely harm- 
less by the invention of ingrafting, which is the term they give 
it. There is a set of old women who make it their business to 
perform the operation every autumn, in the month of September, 
when the great heat is abated. People send to one another to 
know if any of their family has a mind to have the small-pox ; 
they make parties for this purpose, and when they are met — 
commonly fifteen or sixteen together — the old woman comes 
with a nut-shell full of the matter of the best sort of small-pox, 
and asks what veins you please to have opened. She immediately 
rips open that you offer to her with a large needle — which gives 
you no more pain than a common scratch — and puts into the 
vein as much matter as can lie upon the head of her needle, 
and after that binds up the little wound with a hollow bit of 
shell ; and in this manner opens four or five veins. The Grecians 
have commonly the superstition of opening one in the middle 
of the forehead, one in each arm, and one on the breast, to make 

1 The letter is addressed to Mrs. S. C. (Sarah Chiswell). 



336 TEXT-BOOK OF HYGIENE. 

the sign of the cross ; but this has a very ill effect, all these 
wounds leaving little scars, and is not done by those that are 
not superstitious, who choose to have them in the leg or that 
part of the arm that is concealed. The children or young pa- 
tients play together all the rest of the day, and are in perfect 
health until the eighth. Then the fever begins to seize them, and 
they keep their beds two days, very seldom three. They have 
rarely above twenty or thirty in their faces, which never mark ; 
and in eight days' time they are as well as before their illness. 
Where they are wounded there remain running sores during 
the distemper, which I don't doubt is a great relief to it. Every 
year thousands undergo this operation ; and the French ambas- 
sador says pleasantly : ' They take the small-pox here by way of 
diversion, as they take the waters in other countries.' There is 
no example of any one that has died in it, and you may believe 
that I am well satisfied of the safety of the experiment, since I 
intend to try it on my dear little son. 

"I am patriot enough to take pains to bring this useful 
invention into fashion in England; and I should not fail to 
write to some of our doctors very particularly about it, if I knew 
any of them that I thought had virtue enough to destroy such a 
considerable branch of their revenue for the good of mankind. 
But that distemper is too beneficial to them not to expose to all 
their resentment the hardy wight that should undertake to put 
an end to it. Perhaps, if I live to return, I may, however, have 
courage to war with them." 

Soon after the date of this letter the writer's son was 
inoculated in Turkey, and four years later her daughter also, 
being the first subject inoculated in England. The practice 
soon became popular, but several fatal cases among prominent 
families brought it into disrepute, and for about twenty years 
very few inoculations were made in England. It was revived 
about the middle of the century by the founding of a small-pox 
and inoculation hospital in London. This continued in opera- 
tion until 1822. The records of this institution showed that only 



SMALL-POX. 337 

three in a thousand died of the disease thus communicated. The 
practice has now fallen into desuetude, being superseded by vac- 
cination and prohibited by law in England. 

Inoculation was introduced into this country in 1721 by 
Dr. Zabdiel Boylston, of Boston, who had his attention directed 
to the practice by Cotton Mather, the eminent divine. 1 During 
1721 and 1722, 286 persons were inoculated by Boylston and 
others in Massachusetts, and 6 died. These fatal results ren- 
dered the practice unpopular, and at one time the inoculation 
hospital in Boston was closed by order of the Legislature. 
Toward the end of the century an inoculating hospital was again 
opened in that city. 

Early in the eighteenth century inoculation was extensively 
practiced by Dr. Adam Thomson, of Maryland, who was instru- 
mental in spreading a knowledge of the practice throughout 
the Middle States. 2 

In China and India, and perhaps other eastern countries, 
inoculation was practiced at a very early period. 

The inoculation of variolous matter, although it mitigated 
to a very great degree the attack of small-pox following, had 
one very serious objection, aside from the small death-rate which 
was a direct consequence of it. This was the fact that inocula- 
tion always produced small-pox, and thus assisted in propagating 
the disease; for, however mild the induced disease might be, the 
inoculated individual was liable to communicate small-pox to 
others in the most virulent form. Hence, nothing short of uni- 
versal inoculation, which was manifestly impracticable, would 
succeed in reducing the danger from the disease. 

Vaccination. — It had been noticed at various times that a 
pustular disease which sometimes appears on the udders of cows, 
called cow-pox, had not infrequently been transmitted to the 
hands of the dairy-maids and others having much to do with 

1 Dr. John R. Quinan (Md. Med. Journ., June 23 and 30, 1883) believes the claim of Dr. 
Boylston to be the first American inoculator open to question. The evidence presented is, how- 
ever, insufficient to discredit the claim of the Boston physician. 

3 See Quinan, loc. cit., p. 114. 

22 



338 TEXT-BOOK OF HYGIENE. 

cows. In course of time it was also noticed that persons who 
had been thus attacked never suffered from small-pox. This 
protective power of cow-pox was known as early as 1713, and 
in 1774 Benjamin Jesty, a Gloucestershire farmer, performed 
vaccination for the first time on record, inoculating his wife and 
two sons with cow-pox matter as a protection against small-pox. 

It is stated that when it became known that Jesty had 
vaccinated his wife and sons, "his friends and neighbors, who 
had hitherto looked upon him with respect, on account of his 
superior intelligence and honorable character, began to regard 
him as an inhuman brute, who could dare to practice experi- 
ments upon his family, the sequel of which would be, as they 
thought, their metamorphosis into horned beasts. Consequently 
the worthy farmer was hooted at, reviled, and pelted whenever 
he attended the markets in his neighborhood." 1 

In 1791 a school-teacher in Holstein also inoculated three 
boys with the matter of cow-pox, but nothing is known of the 
subsequent history of these cases. 

Although the above facts are clearly established, it is to 
Edward Jenner, a modest country doctor of Berkeley, in the 
county of Gloucester, England, that the merit of demonstrat- 
ing the protective power of cow-pox against small-pox, and of 
diffusing a knowledge of this fact, is due. Jenner had his atten- 
tion directed to the asserted protection conferred by cow-pox 
during the period of his apprenticeship. After a residence in 
London as a pupil of John Hunter, he returned to the country 
to practice his profession. About the year 1776 he began 
studying the question, and gathering evidence of the protection 
afforded against small-pox by the accidental inoculation of cow- 
pox virus. For twenty years he studied the subject, patiently 
awaiting an opportunity to put his belief to the test of experi- 
ment. On the 14th of May, 1796, he made his first vaccination 
on a boy named James Phipps. Six weeks later he inoculated 
this boy with variolous matter, but without success, no small- 

1 London Lancet, September 13, 1862. 



SMALL-POX. 339 

pox resulting. Two years later he published his pamphlet, 
entitled " An Inquiry into the Causes and Effects of the Variola 
Vaccinae, etc.," in which he detailed his observations and experi- 
ments. This publication produced a great sensation in the 
medical world, and, although much opposition was at first 
manifested toward his views, he soon gained many adherents. 

Vaccination, as the operation for the inoculation of cow-pox 
virus is termed, was rapidly introduced into all civilized countries, 
and soon demonstrated its good effects by greatly restricting the 
prevalence of small-pox. It is generally believed that the first 
one to practice vaccination in this country was Dr. Benjamin 
Waterhouse, of Boston, in the summer of 1800; but Dr. John 
It. Quinan has recently shown 1 that vaccination was introduced 
into Maryland, by Dr. John Crawford and Dr. James Smith, at 
least as early as the date generally assigned for its introduction 
into Massachusetts. 

It was believed by Dr. Jenner, and was afterward conclu- 
sively shown by a number of distinguished experimenters, that 
vaccinia, as the disease produced by cow-pox inoculation was 
called, was merely a modification of small-pox as it existed in 
the cow. Small-pox virus, when inoculated upon the cow, 
produced cow-pox ; but the latter, re-inoculated upon man, 
produced cow-pox (vaccinia), and not small-pox. Sheep-pock 
and horse-pock, or " grease," are probably merely modifications 
of the disease produced by inoculating small-pox into those 
animals. 

When cow-pox virus is successfully inoculated into the 
human system — that is, when a person is successfully vaccinated 
— the following local and general symptoms are observed : — 

In the case of a primary vaccination, i.e., where the 
individual has not been previously vaccinated or attacked by 
small-pox, the point where the vaccination is made shows no 
particular change for the first two days. If the vaccination is 
successful, a small, reddish papule appears by the third day, 

1 Quinan, loc. cii., pp. 118, 131. 



340 TEXT-BOOK OF HYGIENE. 

which, by the fifth or sixth day, has become a distinct vesicle of 
a bluish- white color, with a raised edge and a peculiar, central, 
cup-like depression called the umbilication. By the eighth day 
this vesicle has become plump, round, and pearl-colored, the 
central umbilication being still more marked. At this time a 
red, inflamed circle, called the areola, appears, surrounding the 
vesicle and extending usually in a radius of from J to 2 inches 
when fully developed. This inflammatory ring is usually pretty 
firm, and there is more or less general fever and often enlarge- 
ment and tenderness of the axillary glands. After the tenth 
day the areola begins to fade, and the contents of the vesicle 
dry into a hard, brownish crust or scab, which falls off between 
the twentieth and twenty-fourth days, leaving a punctated scar, 
which gradually becomes white. 

When the vaccinia has passed through all of these stages, 
especially if the vesicle filled with pearly lymph, and the areola 
have been well developed, the vaccination may be considered a 
success, and the individual protected against small-pox for a 
number of years, if not for life. Kecently the doctrine has been 
strongly advocated that vaccination is not absolutely protective 
until a subsequent inoculation of vaccine fails to " take." 
According to this view, vaccination should be repeated until it 
foils any longer to exhibit any local reaction. When this has 
been attained the individual may be considered absolutely 
protected for life. Theoretically, this view has much in its 
favor, but there is, as yet, not sufficient evidence to establish it 
as a law. 

It may be stated as an established fact that vaccination, 
although carefully performed and successful, does not confer 
absolute immunity from small-pox for life. The protective 
power seems to wear out after a time and the individual then 
again becomes susceptible to small-pox. An attack of small- 
pox in a vaccinated individual is, however, nearly always much 
milder than where there had been no vaccination. There is no 
fact in the entire range of medicine better established than this : 



SMALL-POX. 341 

that small-pox in vaccinated persons is a much less dangerous 
disease than typhoid fever, while in unvaccinated cases the 
mortality ranges from 30 to 40 per cent. An approximate 
guide to the beneficent influence of vaccination upon the 
mortality from small-pox is furnished by a table in Seaton's 
report on vaccination. Before the introduction of vaccination 
the mortality from small-pox, per million of inhabitants of Eng- 
land, was nearly 3000 per year. After the introduction of vac- 
cination the mortality was reduced to 310 per million per year. 

The most remarkable and convincing statistical evidence 
on the question is given by Drs. Seaton and Buchanan, of 
England. During the small-pox epidemic in London, in 1863, 
they examined over 50,000 school-children, and found among 
every thousand without evidence of vaccination 360 with scars 
of small-pox, while of every thousand presenting some evidence 
of vaccination only 1.78 had any such traces of small-pox to 
exhibit. 1 The reliability of general mortality statistics may be 
called in question — in some cases, with justice ; but the signifi- 
cance of these figures cannot be evaded. 

The upper and outer surface of the arm is usually chosen 
as the point where the virus is inserted, although any part of 
the body which can be protected against friction, or other 
mechanical irritation, may be selected. The method varies 
slightly in the hands of different vaccinators. The two methods 
most frequently in use are scarification and erasion. The 
former method has the indorsement of Mr. Seaton, the high 
English authority. The method of erasion — scraping off the 
epidermis until the papillary layer of the skin is laid bare — is 
now most frequently used in this country. The best instrument 
to use is a clean thumb-lancet ; in default of this, an ordinary 
sewing-needle answers well. Where animal vaccine is used, 
the ivory slip or sharpened quill may also be used with satis- 
faction to make the scarification or erasion. Whatever instru- 
ment is used, it should always be kept perfectly clean. 

1 Seaton, "Vaccination," in Reynolds's System of Medicine, vol. i, p. 291. Second edition. 



342 TEXT-BOOK OF HYGIENE. 

A point of vital importance is that which relates to the 
proper age at which children should be vaccinated. Ordinarily, 
vaccination should be performed within the first six months of 
life. In time of danger from a threatened, or in the presence 
of an actual, epidemic, infants may be vaccinated when only 1 
day old. 

In order to secure permanent protection against small-pox, 
revaccination should be performed after a certain interval. 
Some place the period at which this second vaccination should 
be done at five years, while others allow a longer interval — 
seven, eight, or ten years. The law of Prussia is that every 
child that has not already had small-pox must be vaccinated 
within the first year of its life, and every pupil in a public or 
private institution is to be revaccinated during the year in 
which his or her twelfth birthday occurs. 

This law was passed in 1874. Prior to this time the 
mortality from small-pox was 15 to 20 per 100,000 of the 
population. Since the law was enacted the small-pox mortality 
has varied from 0.3 to 3.6 per 100,000. Not a single death 
from small-pox occurred in the German army between 1874 
and 1882. 1 

A revaccination, even if successful, seldom passes through 
all the typical stages of a primary vaccination. The vesicle 
rarely becomes so full and plump, and is more frequently flat 
and irregular in outline. Swelling of the axillary glands and 
other complications also seem to be more frequent than in cases 
where the vaccination is done for the first time. 

The question whether the lymph direct from the cow or 
humanized lymph is the more efficient has caused much dis- 
cussion. The objections urged against the use of humanized 
virus are : first, that its protective power has become diminished 
by transmission through many generations ; second, that it is 
liable to transmit other diseases, such as syphilis, tuberculosis, 
scrofula, etc. ; third, that it is frequently difficult to obtain in 

1 Frolich, Militar-Medicin, p. 461. 



SMALL-POX. 343 

sufficient quantities in an emergency, such as an actual or 
threatened epidemic. 

The first objection is disproved by the testimony of many 
of the most distinguished medical men in Europe and this 
country. Humanized vaccine virus, when properly inoculated, 
seems to be as completely protective against small-pox as that 
taken direct from the animal. Among its advantages are, that 
it " takes " more readily and runs through its stages of develop- 
ment in a shorter time, and that it will retain its active proper- 
ties for a greater length of time than animal virus. The 
physician can usually control the source whence he obtains it. 
He can watch over the subject that furnishes it and reject that 
which is suspicious. With humanized lymph collected by the 
physician himself there can be no doubt as to its purity or age ; 
with animal lymph furnished by the cultivators of that article 
there can be no certainty about either of these important points. 

That syphilis has been inoculated with humanized virus 
can no longer be open to doubt. The recent experiment of 
Dr. Cory, of England, has settled this question definitely. With 
care, however, this sad accident can easily be avoided, and the 
fact that syphilis has been so rarely transmitted by vaccination 
is sufficient evidence that the danger of such infection is not 
very great. 

The most serious objection against the exclusive use of 
humanized lymph is, that in grave emergencies, such as a 
rapidly-spreading epidemic of small-pox, it is difficult to obtain 
a sufficient supply of the lymph. 

Humanized virus is inoculated, either in the fresh state, 
i.e., the lymph is taken from the vesicle on the seventh day and 
inoculated directly into the arms of other individuals, or else the 
vesicle is allowed to dry into a crust, with which a thin paste is 
made by moistening with water at the time of vaccination. The 
readiest way of using the crust is to crush a small fragment 
between two small squares of glass, then moistening it with a 
drop of warm (not hot) water, and smearing it on the spot 



344 TEXT-BOOK OF HYGIENE. 

where the vaccination is to be made. With the lancet a 
number of cross-scarifications are then made, and the virus well 
rubbed in. Only so much of the crust should be moistened as 
will be used at the time. Particular care must be taken not to 
use saliva for moistening the crust. Aside from being unclean, 
there is danger of producing blood-poisoning by inoculating 
certain of the oral secretions. 1 

Animal virus is obtained by inoculating a calf or heifer 
with virus, either derived from a case of small-pox, from another 
case of cow-pox, or by re-inoculating humanized vaccine virus 
into the animal. The vesicles are opened on the seventh day, 
and ivory points or the ends of quills coated with the lymph 
and dried with a gentle heat. 

In vaccinating with animal virus, the quill or ivory point 
is first moistened with a drop of water to soften the adhering 
lymph ; the scarification or abrasion of the skin is then made 
with the lancet, and the virus rubbed well into the scarified 
spot. 

In using animal virus the successive stages of development 
are usually one or two days later than when humanized virus 
is used. In the former case the areola is rarely developed 
before the ninth day. 

Certain complications are likely to occur in the course of 
the vaccinia, of which the student should be aware. 

When the areola appears there is usually more or less 
fever. Sometimes the constitutional manifestations are de- 
cidedly marked, fever of a high grade being not uncommon. 
In addition to the glandular enlargement and tenderness, an 
outbreak of roseola sometimes comes on about the ninth or 
tenth day. This eruption may be mistaken for scarlet fever, 
but if it is remembered that two infectious diseases rarely co- 
exist in one individual during their full development this error 
will be avoided. 

Erysipelas involving the entire arm is sometimes observed 

1 See Sternberg and Magnin, Bacteria, p. 355. Second edition. 



SMALL-POX. 345 

as a complication of vaccination. This, in nearly every case, 
depends upon some depravement of the patient's constitution, 
innutrition, bad sanitary surroundings, or, perhaps, more fre- 
quently, chronic alcoholism. Individuals who are habitually 
intemperate in the indulgence of alcoholic liquors are espe- 
cially unfavorable subjects for vaccination. The results are, 
fortunately, rarely serious to the patient. 

Another inconvenient complication of vaccination is the 
formation of a deep, ill-looking, sloughing ulcer at the vacci- 
nated point. This has been, in the author's experience, a much 
more frequent concomitant when animal virus has been used than 
when humanized virus was resorted to. It should be borne in 
mind that a very sore arm, especially if followed by the formation 
of an ulcer or gangrenous sore, may not be protective against 
small-pox. Such a patient should not be considered properly 
vaccinated, and must be revaccinated as soon as he recovers, or 
immediately if there is any danger of small-pox infection. 

Children with eczematous eruptions, however, localized 
upon any portion of the body, should not be vaccinated until 
the eruption is first cured, except in times of danger from 
small-pox. The eczema will be almost certainly rendered worse 
in consequence of the general hyperemia accompanying the 
febrile reaction, and the physician who performs the vaccination 
will be blamed for causing the skin disease. 

The author has placed on record 1 two cases of general 
psoriasis following vaccination, and other cases have been since 
reported. Urticaria and exudative erythema have also been 
repeatedly observed. 

As before stated, syphilis may be communicated to the 
vaccinee by vaccine virus obtained from a syphilitic subject, but 
this accident is infrequent. There can be little doubt that some 
of the cases reported as " vaccinal syphilis " are cases of tardy 
hereditary syphilis, lighted up by the general systemic disturb- 
ance following vaccination. 

1 Journal Cutaneous and Venous Diseases, vol. i, No. 1, p. 11. 



346 TEXT-BOOK OF HYGIENE. 

Next in importance to vaccination in the prophylaxis of 
small-pox is prompt isolation of the sick. No one but the 
medical and other attendants of the sick should be allowed to 
come in contact with them. All attendants and other persons 
exposed to the infection should, of course, be promptly vacci- 
nated, unless this has been successfully done within the previous 
year or two. Disinfection of all discharges from the patient and 
of the room and its contents, after the patient has recovered or 
died, must be practiced. The best disinfectants in small-pox are 
bichloride of mercury, free chlorine, and sulphurous acid. 

When it is learned that a person has small-pox, if he is not 
removed to a special hospital, a room should be prepared for his 
occupancy. The carpets should be taken up and the floor kept 
clean. Window-curtains and unnecessary furniture and drapery 
should be removed from the room. After recovery of the 
patient the bed-clothing must be thoroughly disinfected with 
steam or sulphurous acid, or destroyed by fire. The individual 
himself should not be allowed to mingle with healthy persons 
until all danger of infection is passed and the surface of his 
body has been thoroughly disinfected. 

At a recent conference of sanitary officials in the city of 
Chicago (May, 1894) the following propositions were adopted. 
They represent the most advanced conclusions of competent 
authority upon the most practical means of limiting the spread 
of small-pox : — 

" 1. The city should be divided into districts containing 
not more than 10,000 people. 

" 2. Each district should be placed under the supervision 
of a competent medical inspector with necessary assistants to 
(a) make a house-to-house inspection ; (b) to successfully vacci- 
nate, within the shortest possible time, all persons who have not 
been vaccinated during the outbreak, and that the first vaccina- 
tion be within seven days ; (c) to properly disinfect all houses 
and their contents where small-pox occurs. 

" 3. Necessary means and appliances for efficient disinfec- 



ASIATIC CHOLERA. 347 

tion of materials, premises, etc., should be provided as the 
exigencies of each district may require. 

" 4. Each case of small-pox should be immediately removed 
to a suitably constructed and properly equipped and officered 
isolation hospital. 

" 5. Except in extreme cold weather, hospital tents, as 
prescribed in the United States Army Regulations, floored and 
warmed, are preferable to the average hospital or private dwell- 
ing, and increase the chances of recovery of the patients. Cases 
of small-pox necessarily detained in their own homes should, with 
their attendants, be rigidly isolated during the period of danger, 
and physicians visiting such patients professionally shall be sub- 
ject to such regulations as may be prescribed by the local health 
officer. 

" 6. Persons exposed to small-pox contagion should be 
immediately vaccinated or re vaccinated, and kept under observa- 
tion for not less than fourteen days from time of last exposure. 

" 7. It is the sense of this conference that where such 
measures are all enforced it will not be necessary for neighbor- 
ing cities and states to exclude all persons who come from such 
city who are not protected against small-pox by vaccination, and 
to require disinfection of all baggage and merchandise capable 
of conveying small-pox infection." 

ASIATIC CHOLERA. 

A disease which causes the death of three-fourths of a 
million of human, beings where it is endemic within the space 
of five years, and which makes periodical excursions, spreading 
over nearly the entire inhabited globe with destructive violence, 
must surely command the interested attention of every intelli- 
gent person. Asiatic cholera is endemic in India, where it 
probably originated centuries ago. Some authors claim to have 
found satisfactory evidence of its existence in the writings of the 
classical authors of India and Greece at a period as early as the 
second century of the Christian era. The evidence is, however, 
not beyond question. In the sixteenth and seventeenth cen- 



348 TEXT-BOOK OF HYGIENE. 

turies European travelers in the East gave pretty exact accounts 
of the disease. One of the most definite of these was given by 
Gaspar Correa, an officer in Vasco da Gama's expedition to 
Calicut. He states that Zamorin, the chief of Calicut, lost 
20,000 of his troops by the disease. A still more definite and 
the first trustworthy account is that of Sonnerat, a French trav- 
eler. He describes a pestilence having all the characters now 
recognized as belonging to Asiatic cholera, which prevailed in 
the neighborhood of Pondicherry and the Coromandel coast in 
1768 and 1769, and which carried off 60,000 of those attacked 
by it within a year. Dr. Macpherson, in his " History of Cholera," 
gives numerous references which indisputably establish the en- 
demic existence of the disease in India anterior to the present 
century. 

Being endemically prevalent over a greater or less area of 
India for many years, cholera finally, in 1817, crossed the 
boundaries of that country, and, advancing in a southeasterly 
direction, invaded Ceylon and the Sunda Islands in 1818. In a 
westerly direction the disease was carried to the islands of 
Mauritius and Reunion, and reached the African coast in 1820. 
During this year it also traveled northeasterly, devastating the 
Chinese Empire for the two following years, reaching Nagasaki, 
in Japan, in 1822. 

In 1821 the disease spread from India in a westerly direc- 
tion, extending along the east coast of Arabia to the border of 
Mesopotamia and Persia. In the spring of 1822 it began with 
renewed violence, following the river Tigris to Kurdistan, and, 
extending farther in a westerly direction, reached the Mediter- 
ranean coast of Syria. In the following year, 1823, it extended 
from Persia into Asiatic Russia, reaching Astrachan on the 
European border in September, but dying out nearly every- 
where beyond the borders of India during the ensuing winter. 

In 1826 cholera again advanced from India, reaching 
Orenburg in Russia in 1829, and in the following winter 
appeared in St. Petersburg. Extending to the north and south, 



ASIATIC CHOLERA. 849 

it invaded Finland and Poland the same year. From Persia the 
disease spread to Egypt and Palestine in 1830-31. 

From Russia the pestilence invaded Germany in 1831, 
passing thence in 1832 into France, the British Isles, Belgium, 
the Netherlands, Norway, and Sweden. In the latter year 
cholera crossed the Atlantic Ocean for the first time, being car- 
ried to Canada by emigrants from Ireland, and spreading thence 
to the United States by way of Detroit. In the same year it 
was imported into New York by emigrants, and rapidly spread 
along the Atlantic coast. During the winter of 1832 it appeared 
at New Orleans, and passed thence up the Mississippi Valley. 
Extending into the Indian country, causing sad havoc among 
the aborigines, it advanced westward until its further progress 
was stayed by the shores of the Pacific Ocean. In 183-4 it 
re-appeared on the east coast of the United States, but did not 
gain much headway, and in the following year New Orleans was 
again invaded by way of Cuba. It was imported into Mexico in 
1833. In 1835 it appeared for the first time in South America, 
being restricted, however, to a mild epidemic on the Guiana coast. 

While the pestilence was advancing in the Western Hemi- 
sphere, it also spread throughout Southern Europe, invading, in 
turn, Portugal, Spain, and Italy. 

Extending in an easterly direction from India, the disease 
reached China and Japan in 1830-31 ; westwardly, Africa 
was invaded in 1834, and ravaged by the epidemic during the 
following three years. 

This second extensive outbreak of cholera ended in 1837, 
disappearing at all points beyond the borders of India. In 
1846 the disease again advanced beyond its natural confines, 
reaching Europe, by way of Turkey, in 1848. In the autumn 
of this year it also appeared in Great Britain, Belgium, the 
Netherlands, Sweden, and the United States, entering by way of 
New York and New Orleans. In the succeeding two years the 
entire extent of country east of the Rocky Mountains was in- 
vaded. During 1851 and 1852 the disease was frequently im- 



350 TEXT-BOOK OF HYGIENE. 

ported by emigrants, who were annually arriving in great num- 
bers from the various infected countries of Europe. In 1853 
and 1854, cholera again prevailed extensively in this country, 
being, however, traceable to renewed importation of infected 
material from abroad. In the following two years it also broke 
out in numerous South American States, where it prevailed at 
intervals until 1863. 

Hardly had this third great pandemic come to an end 
before the disease again advanced from the Ganges, spreading 
throughout India, and extending to China, Japan, and the East 
India Archipelago during the years 1863 to 1865. In the latter 
year it reached Europe by way of Malta and Marseilles. It 
rapidly spread over the Continent, and in 1866 was imported into 
this country by way of Halifax, New York, and New Orleans. 
This epidemic prevailed extensively in the Western States, but 
produced only slight ravages on the Atlantic coast, being kept 
in check by appropriate sanitary measures. In the same year 
(1866) the disease was also carried to South America, and in- 
vaded, for the first time, the States bordering on the Rio de la 
Plata and the Pacific coast of the Continent. 

While the epidemic was thus advancing westward from its 
home in India, it was at the same time spreading northwardly 
over the entire western part of Asia, and in a southeasterly 
direction over Northern Africa. In the latter continent it pre- 
vailed from 1865 to 1869. 

Cholera never entirely disappeared in Russia during the 
latter half of the sixth decade, and in 1870 it again broke out 
with violence, carrying off a quarter of a million of the inhabi- 
tants before dying out in 1873. It spread from Russia into 
Germany and France, and was imported, in 1873, into this 
country, entering by way of New Orleans and extending up 
the Mississippi Valley. None of the Atlantic-coast cities suf- 
fered from the epidemic in 1 873, and since that year the United 
States have been entirely free from the disease, with the excep- 
tion of a few imported cases in New York Harbor in 1887. 



ASIATIC CHOLERA. 351 

In June, 1883, a new epidemic of cholera broke out in 
Egypt, where it raged with great violence. The disease first 
appeared in Damietta, near the outlet of the Suez Canal. It 
was unquestionably imported from India, probably Bombay, 
where it prevailed as early as the month of May. At the time 
of the outbreak in Damietta that city was overcrowded with 
people who had come to attend a great religious fair and festival. 
It has been proven that pilgrims from Bombay were among the 
attendants at this fair. The epidemic came to an end in Egypt 
in the autumn of 1883. In the same year (1883) a small out- 
break occurred in Marseilles, but intelligence of it was carefully 
suppressed by the authorities. The disease does not seem to 
have spread from this centre, but in June of the following year 
cholera broke out in Toulon, having probably been imported in 
a transport ship returning from Tonquin. This outbreak was 
very violent and rapidly spread throughout Southern France, 
Italy, and Spain. After apparently dying out during the winter, 
it re-appeared in the spring of 1885 with renewed violence. The 
total number of cases in Spain alone in the latter year was over 
one-third of a million, with nearly 120,000 deaths. 

In the summer of 1885 cholera also broke out in a viru- 
lent form in Japan, and, after a cessation during the following 
winter, recurred with increased fatality in 1886. In the latter 
year there were over 100,000 deaths from the disease in that 
country. 

During 1886 and 1887 cholera continued in Southeastern 
Italy and in the Austrian dominions at the head of the Adriatic. 
A few cases occurred in France and Germany, but by stringent 
sanitary measures an epidemic was averted. 

In November, 1886, cholera was carried to South America 
in an Italian ship, the "Perseo," bound from Genoa to Buenos 
Ay res. The disease rapidly spread in the Argentine Republic, 
and, crossing the Andean range, invaded the Pacific coast of the 
South American continent for the second time, reaching Chili 
and Bolivia and threatening Peru and Brazil. In Chili alone 



352 TEXT-BOOK OF HYGIENE. 

there were over 10,000 deaths in the first six months of 1887. 
The further progress of the epidemic was arrested and the entire 
Western Hemisphere is now free from the disease. 

From July to December, 1889, cholera prevailed with con- 
siderable virulence in Mesopotamia. In 1890 it re-appeared in 
Spain; in 1892 in France and Germany, raging with great vio- 
lence in Hamburg. Nearly 8000 persons died from the disease 
in the latter city. Some cases were brought thence to New 
York Harbor, but the active sanitary measures taken were suc- 
cessful in preventing its further spread. At the present writing 
(August, 1894), the disease again threatens Europe. 

This brief historical sketch of all the epidemics of cholera 
observed beyond the borders of India demonstrates several facts : 
first, that the home or breeding-place of cholera is in India, 
especially the delta of the Ganges, whence it spreads at intervals 
throughout the world ; second, that it always advances along the 
lines of travel of large bodies of human beings ; and, third, that 
it advances, by preference, along water-routes. Exceptions un- 
doubtedly occur, but the rule is a general one. The disease 
seems to spread with difficulty along the lines of railroad. When 
the disease has extended from New Orleans it has always been 
up the Mississippi Valley, expending its violence upon the river 
cities — Vicksburg, Memphis, St. Louis, and Cincinnati. 

Several factors must concur before there can be an epidemic 
of cholera. These are : first, the cholera poison ; second, cer- 
tain local conditions of air, soil, or water ; and, third, individual 
predisposition. Without a concurrence of all these conditions 
no outbreak can occur. If, by any means, the co-existence of 
these three conditions can be prevented, cholera can be averted. 
The following are facts bearing upon this question : Cholera is 
communicated through the agency of a specific poison. This 
does not admit of doubt. The poison may be either an organic 
germ, or of an inorganic, particulate, or gaseous nature. The 
recent researches of Dr. Robert Koch, of Germany, indicate 
that a micro-organism found in the intestinal discharges of cholera 
patients and in the bodies of those dead with the disease is the 



ASIATIC CHOLERA. 353 

active agent in propagating the malady. This organism, named 
by Koch the "comma bacillus," from its general resemblance 
to a comma, was first discovered by this eminent pathologist in 
the intestinal contents of cholera corpses in Egypt in 1883, and 
in the following year more thoroughly studied in Calcutta, 
whither he had been sent by the German government to pursue 
his investigations. It has been demonstrated that this germ is 
always present in the discharges of cholera patients, and up to 
this time it has not been found in any other disease. Experi- 
ments upon animals have also shown that cholera can be pro- 
duced in the latter by introducing the germ into their bodies in 
various ways. The demonstration of the bacterial nature of 
cholera seems to be complete. 

While cholera cannot be regarded as personally contagious 
in the same sense or in the same degree as small-pox, there can 
be no doubt that it is spread only by the poison from other cases 
of the disease. The regularity of its march along routes by 
which the intercourse of human beings takes place, and always 
in connection with other cases of cholera, proves this. There is 
no undoubted case on record where genuine cholera has been 
spontaneously developed outside of India. 

That certain local geological and perhaps meteorological 
conditions are necessary for the propagation or virulence of the 
poison of cholera is beyond dispute. Outbreaks usually take 
place during the summer or autumn, and nearly always partly 
or entirely die out during cold weather. Further, in nearly all 
epidemics, certain cities or towns, or portions of a town, into 
which persons sick with cholera are brought, and where the 
poison of the disease is thus imported, remain exempt from the 
effects of the epidemic. The inference to be drawn from this 
fact is that in such localities the local conditions are unfavorable 
to the development of the poisonous germ, and it becomes inert. 

In India all the local conditions favorable to the propagation 
of the cholera-germ are found. The filthy personal habits of 
the people, the overcrowding, the intense heat, the lack of suf- 

23 



354: TEXT-BOOK OF HYGIENE. 

ficient, appropriate, or properly-prepared food, and the exten- 
sive pollution of the water-supply, all combine to produce the 
necessary conditions of development of the cause of cholera. 
These conditions, doubtless, to a considerable extent, give rise 
to that depression of the system which seems necessary to con- 
stitute the individual predisposition to become infected. 

Given, then, at any place, a number of persons of a lowered 
degree of vitality, — that is to say, persons not capable of resisting 
unfavorable influences upon their health under unfavoring con- 
ditions ; given conditions of climate, water, and soil more or less 
similar to those existing in India : only the introduction of the 
third factor, the cholera poison, is needed to cause an outbreak. 
In many cities of this country and Europe, as proven by the 
most recent epidemics in Toulon, Marseilles, Naples, and other 
cities of Italy and Spain, the conditions are present which would 
furnish the most favorable breeding-place for the cholera-germ 
if introduced. 

The dejections and vomited matters of cholera patients con- 
tain the active agent which produces the disease. The contagi- 
ous principle contained in these excretions, probably the cholera- 
germ or " comma bacillus " discovered by Koch, may gain an 
entrance into the body through the drinking-water or through 
infected air. Probably both modes are equally competent chan- 
nels of infection. The prevailing theory is that pollution of the 
drinking-water is the most frequent source of the rapid spread 
of the disease. A very striking instance of this occurred in 
London during the epidemic of 1854, which has already been 
referred to. 1 

Another striking instance of the communication of cholera 
by polluted water has been reported by Mr. John Simon, long the 
chief medical officer of the English "Local Government Board." 
The facts are as follow : The Lambeth Water Company drew 
its supply from the Thames, at Ditton, above the influence of 
the London sewage and the tidal flux. The Southwark and 

1 See ante, page 64. 



ASIATIC CHOLERA. 355 

Vauxhall Company drew its supply from the river near Vauxhall 
and Chelsea. The water of the Lambeth Company was toler- 
ably pure, and that of the South wark and Vauxhall Company 
was very impure. The water of both companies was distributed 
in the same district at the same time and among the same class 
of people, the pipes of the two companies being laid pretty 
evenly in the same areas, in many places running side by side 
in the same streets, and the houses supplied being pretty equally 
distributed. The deaths from cholera in the houses supplied by 
the Lambeth Company were at the rate of 37, and in the houses 
supplied by the South wark and Vauxhall Company at the rate 
of 130, to every 10,000 persons living. It appears, therefore, 
that of the drinkers of the foul water about three and a half 
times as many as those who drank the pure water died of cholera. 

But the spread of cholera cannot always be referred to pol- 
lution of the drinking-water. In many epidemics no relation 
can be shown to exist between the spread of the disease and im- 
pure water. Professor von Pettenkofer, of Munich, has shown, 
by a number of carefully-conducted observations, that the prop- 
agation of cholera often bears a very direct relation to changes 
in the stage of the subsoil- or ground- water. This does not 
mean that the subsoil-water is directly or necessarily the agent 
for the spread of the disease, but that its stage, or variability, — 
now high, now low, — may be considered as an index of certain 
processes going on in the soil which are intimately connected 
with the propagation of cholera as well as of certain other in- 
fectious diseases, chief among which is typhoid fever. The 
relations between the ground-water level and cholera outbreaks 
in India and various cities in Europe and America give strong 
support to the views of von Pettenkofer. 1 The relation of the 
ground- water oscillations to pollution of water in wells, when 
thoroughly worked out will probably explain discrepancies which 
at present apparently exist. 

In addition to the influence of the ground-water oscillations 
and polluted drinking-water in spreading the cholera-poison, 

* See page 140. 



356 TEXT-BOOK OF HYGIENE. 

must be mentioned articles of food contaminated with the in- 
fectious matter of the disease. It is also no longer open to 
question that persons may become infected by handling the 
clothing and bedding of cholera patients. Laundresses are in 
special danger from this source. 

The prophylaxis against cholera comprises such measures 
as will prevent the admission of the cholera-poison into a com- 
munity, arrest the development of the poison after its introduc- 
tion, and reduce the individual susceptibility to attack. 

It is evident from the foregoing that if the introduction of 
the cholera-poison could be prevented no outbreak of the dis- 
ease could occur. With this in view, some have urged the en- 
forcement of a strict policy of non-intercourse with infected 
localities. But at the present day few sanitarians advocate these 
extreme measures. A modified system of restricted intercourse 
is supported by many authorities, who claim that by the adoption 
of a thorough system of maritime inspection, disinfection, and 
observation — a rational quarantine, in fact — the poison can be 
rendered ineffective or its entrace into a commmunity prevented. 

The best authorities, however, think that it is not only 
easier, but far more effective to place the threatened locality in 
such a sanitary condition that the development of the cholera- 
poison cannot take place. The contrast between the effective- 
ness of quarantine and local sanitation as safeguards against 
cholera has been well expressed by von Pettenkofer, who com- 
pares cholera epidemics to powder explosions. The virus of 
cholera, he says, is the spark that evades the strictest quaran- 
tine ; the powder is the ensemble of local conditions which pre- 
dispose to the outbreak. "It is wiser, therefore, to seek out and 
remove the powder than to run after and try to extinguish each 
individual spark before it drops upon a mass of powder, and, 
igniting it, causes an explosion which blows us into the air with 
our extinguishers in our hands." 

The measures of local sanitation to be enforced are such 
as will secure cleanliness of person, of habitation and surround- 



ASIATIC CHOLERA. 357 

ings, of air, of water, and of soil. Pollution of the soil should 
be especially guarded against, for a polluted soil means impure 
air and water, and these mean, if not an infectious disease, 
at least a heightened receptivity to its influence. The quality 
of the drinking-water used must be above suspicion of con- 
tamination by the poison. Unless the latter can be positively 
excluded all drinking-water should first be boiled. It may then 
be cooled by pure ice. Filtering the water may not remove the 
poison. 

The individual predisposition to cholera is best guarded 
against by keeping the body clean and well nourished, and the 
mind free from worry. Underfeeding, anxiety, overwork, ex- 
posure to extremes of temperature, intemperance in eating and 
drinking should all be avoided, as they tend to reduce the re- 
sistance of the system to the influence of the morbid poison. 

Certain measures of personal prophylaxis which have 
proven useful heretofore should be adopted wherever cholera 
prevails. One of the best of these is the use of sulphuric-acid 
lemonade as a drink. Ten to 15 drops of dilute sulphuric acid 
in a glass of water, sweetened with sugar, may be drunk instead 
of water. Experience with it during the epidemic of 1866 has 
demonstrated its great value as a preventive of cholera. The 
later researches of Koch have also shown that the "comma 
bacillus, ,, or spirillum, cannot live in acid solutions. Hence, 
it is probable that if the contents of the stomach were always 
kept acid no infection could occur through absorption from the 
stomach. 

A painless diarrhoea, called cholerine, attacks many persons 
during cholera epidemics. This disorder is easily curable if 
promptly attended to, but if allowed to run on it may develop 
into a malignant attack of cholera. 

Among the means of securing prompt treatment of the 
poorer classes in times of epidemics is the establishment of 
numerous public dispensaries, where medical aid can always be 
obtained. The establishment of such dispensaries and, if 



358 TEXT-BOOK OF HYGIENE. 

possible, of temporary hospitals in the crowded portions of 
cities is a very important part of the prophylactic treatment. 

Inasmuch as it seems definitely established that the dis- 
charges from the stomach and intestines are the active agents in 
propagating the disease, the immediate disinfection of such dis- 
charges is vitally important. The stools and vomited matters 
must be rendered innocuous by germicidal agents, such as mer- 
curic chloride, carbolic acid, or chloride of lime. 

Clothing and bedding should be disinfected with super- 
heated steam, thorough boiling, or fumigation with sulphur 
dioxide or chlorine. Infected articles of this kind should not 
be sent to a laundry until they have been thoroughly disinfected 
by one of the above-mentioned means. 

Apartments which have been occupied by cholera patients 
should be thoroughly fumigated, before being re-occupied, with 
burning sulphur, and afterward freely exposed to the air by 
opening doors and windows. The walls may also be washed 
with a solution of mercuric chloride. 

The most efficient disinfectant is mercuric chloride in the 
proportion of 1 part in 2000 of the material to be disinfected. 
The readiest way of securing disinfection with this agent is to 
add a solution of 1 to 1000 to an equal proportion of the dis- 
charges to be rendered innocuous. The mercuric chloride acts 
slowly, and hence the infected material should be exposed to the 
action of the disinfecting agent for at least two hours before it 
can safely be thrown into sewers or cess-pools. 

There are several serious objections to the indiscriminate use 
of mercuric chloride by the public as a disinfectant. In the 
first place, it is intensely poisonous, and its perfectly transparent 
and inodorous solution might readily be accidentally drunk and 
cause fatal results. To reduce this danger, the Committee on 
Disinfectants of the American Public Health Association recom- 
mended the addition of permanganate of potash or of sulphate 
of copper (blue vitriol) to color the solution. Another serious 
objection to mercuric chloride is that it cannot be used where 



3 



ASIATIC CHOLERA. 359 

the disinfected material must pass through lead pipe, as this is 
rapidly corroded by the sublimate. In many water-closets it can 
therefore not be used. 

Chloride of lime (bleaching-powder) has been found to be 
a very rapid and efficient disinfectant, as well as a deodorizer ; 
but the chlorine, upon which its effectiveness depends, is often 
so deficient in proportion, and the compound so readily deterio- 
rates that, unless a preparation can be obtained that contains at 
least 25 per cent, of available chlorine, it may prove injurious 
by causing a false sense of security. A trustworthy preparation 
may be dissolved in water, when required, in the proportion of 
1 to 100. An objection to its use is the pungent odor of chlorine, 
which is very offensive to many persons. 

Dr. Koch recommends carbolic acid, which he has shown 
will kill the " comma bacilli " in a dilution of 1 to 20 of water. 
The ordinary preparations of carbolic acid sold as disinfectants 
are, however, not to be relied on, many of them not containing 
more than 2 per cent, of the acid. Further dilution of these 
agents would altogether destroy their disinfecting power. The 
purer article is, on the other hand, too expensive to be used as 
a disinfectant. 

Little's soluble phenyle is an efficient disinfectant in the 
proportion of 2 per cent. (1 to 50). It is furnished of uniform 
strength, is moderately cheap, non-poisonous, and readily 
miscible with water. In addition to its disinfecting power, it is 
also an excellent deodorizer, promptly removing all odors of 
decomposition and putrefaction. Its only objection is a rather 
pungent though not unpleasant odor, which somewhat resembles 
creasote. 

In the very beginning of an epidemic, prompt isolation of 
the sick and thorough disinfection of the surroundings of the 
patient may check the spread of the disease. Much cannot be 
expected from these measures, however, unless the local sanitary 
conditions are such as offer a hindrance to the development of the 
cholera-poison. It is plain, therefore, that prophylactic measures 



360 TEXT-BOOK OF HYGIENE. 

against cholera, to be effective, must be brought into requisition 
before the epidemic has begun. After the outbreak of the 
disease it may be too late to put the threatened locality in a 
good sanitary condition. It is of the highest importance that 
preventive measures be enforced early. Above all, the purity 
of the drinking-water must be safeguarded. 

RELAPSING FEVER. 

Relapsing fever was first clearly described by Dr. John 
Rutty, in his " Chronological History of the Weather, Seasons, 
and Diseases of Dublin from 1725 to 1765." * Near the end of the 
last and in the first half of the present centuries relapsing fever 
was frequently met with in an epidemic form in Ireland and 
Scotland. In 1847 the disease invaded a number of the larger 
cities of England. From 1868 to 1873 it prevailed extensively 
in England and Scotland. On the continent of Europe it was 
first observed in Russia in 1833. In Germany it was not 
recognized as a distinct disease until 1847, but did not prevail 
epidemically until 1868. Since then it has often been observed 
in that country. 

Relapsing fever is very prevalent in India, where it was 
first observed in ,1856 by Sutherland. In China and in the 
countries of Africa bordering on the Red Sea the disease has 
been recognized by observers. 

In the United States it was first observed among emigrants 
in Philadelphia in 1844, and again in 1869. It was conveyed 
to other places, but has never prevailed extensively in this 
country. It has not been observed in the United States since 
1871. 

The predisposing causes of relapsing fever are, above all, 
bad sanitary surroundings. Want and overcrowding seem to be 
much less important factors than in typhus fever. 

Although relapsing fever has, since it was first clearly dis- 
tinguished from typhus and other continued fevers, been recog- 
nized as an eminently contagious and infectious disease, it was 

1 London, 1770. 



TYPHOID FEVER. 361 

not until 1873 that its immediate cause became known. In that 
year Obermeier discovered in the blood of patients ill with this 
disease a minute, spiral, mobile organism, now known as the 
spirillum or spirochcete Obermeieri. 

Obermeier and other observers, prominent among whom is 
Dr. Henry V. Carter, have demonstrated the constant presence 
of these organisms in the blood during the attack. Carter and 
Koch have induced the disease in monkeys by inoculation of the 
parasite, and Moschutkowski has successfully inoculated it in the 
human subject. No doubt can exist at the present day that the 
spirillum of Obermeier is the true cause of relapsing fever. 

The preventive measures consist in attention to details of 
personal hygiene ; in other words, local sanitation, disinfection 
of infected materials (fomites), and complete isolation of the sick. 

TYPHOID FEVER. 

The first accurate clinical accounts of typhoid fever date 
from the seventeenth century, when Baglivi, Willis, Sydenham, 
and others described cases of fever which in their clinical char- 
acters correspond to the disease now known as typhoid fever. 
Strother, however, in 1729, first gave a description of the 
anatomical characters of the disease, which he says is a " symp- 
tomatical fever, arising from an inflammation, or an ulcer, fixed 
on some of the bowels." Bretonneau and Louis, in France; 
Hildenbrand, in Germany ; William Jenner, in England ; and 
Drs. Gerhard and Pennock, in this country, clearly pointed out 
the essential distinction between typhoid and other fevers, during 
the first half of the present century. 

At the present day typhoid fever is met with everywhere 
throughout the world. It is at nearly all times a constituent of 
mortality tables. It affects by preference persons between 
the ages of 15 and 30 years, although no age is entirely 
exempt. It is always more prevalent in the autumn and winter. 

The disease is probably due to an organic poison, which 
gains entrance into the body through the respiratory or digestive 



362 TEXT-BOOK OF HYGIENE. 

tract. Recent observations of Eberth, GafTky, and others seem 
to. indicate that the morbific agent is a micro-organism termed 
the bacillus typhoideus. The exact relation of this organism to 
the disease has not been clearly worked ont. It is found in the 
intestinal canal, and especially in the characteristic intestinal 
lesions of this fever. The infective agent is probably contained 
in the dejections of patients. The disease is not immediately 
contagious, like typhus fever. 

The medium through which the poison is introduced into 
the body may be drinking-water, food, milk, or other articles 
containing the infective agent. Localized epidemics due to 
infected water or milk have been frequently reported. 1 

The typhoid poison is supposed to be developed in cess- 
pools, sewers, and soil polluted by the products of animal decom- 
position. Whether it ever originates de novo in such places is 
a much-disputed proposition. At present the evidence is in 
favor of the view that cases of typhoid fever are always derived 
from pre-existing cases. The germ may develop in sewers and 
be carried in the sewer-air from place to place ; it may be carried 
into the soil from cess-pools receiving typhoid dejections, and 
there, undergoing development, may ascend through houses 
with the ground-air, or may drain into wells and pollute the 
drinking-water. By the admixture of such water with milk or 
other food the disease may be propagated. It is also believed 
that the effluvia from typhoid discharges may be absorbed by 
water or milk, and thus infect these articles. 

The prophylactic measures against typhoid fever comprise 
isolation of the sick, prompt disinfection of the discharges, and 
cleanliness in the widest sense. The water- and food- supplies 
must be carefully guarded against contamination with the poison, 
and all decomposing animal matter and excreta must be removed 
from the immediate vicinity of dwellings. The requisites for 
prevention may be summed up as pure air, pure water, uncon- 
taminated food, and a clean soil. 

1 See ante, pp. 61-64. 



TYPHUS FEVER. 363 

TYPHUS FEVER. 

Wide-spread pestilences are nearly always accompaniments 
of famine and Avar. Of all pestilential diseases, none is so regu- 
lar in its coincidence with these conditions as typhus fever. The 
earliest accounts which unquestionably refer to this disease date 
from the eleventh century, when it was observed at a number of 
places in Italy.. In the succeeding centuries isolated accounts 
of it appeared in the chronicles of the times, but no scientific 
description of it appeared until the sixteenth century. During 
the seventeenth, eighteenth, and the early part of the nineteenth 
centuries it prevailed extensively throughout Europe. The 
constant wars and consequent disturbances of the social rela- 
tions of the people, famines, overcrowding, filth, excesses of all 
kinds, contributed largely to the development and spread of 
typhus fever. For a number of years past no extensive epi- 
demic of the disease has been observed, although both in this 
country and in Europe localized outbreaks are frequently met 
with. 

Typhus fever is somewhat more prevalent in the winter and 
early spring months than during the rest of the year, but not 
very markedly so. 

At present, typhus fever is nearly always limited to times 
and places where the conditions favoring its development exist. 
Wherever overcrowding, in connection with filth, insufficient 
food, and bad habits are present, typhus fever is likely to be a 
visitor. Thus, in overcrowded and ill-ventilated emigrant ships, 
in jails and work-houses, and in camps, especially when stress 
of weather compels the crowding together of soldiers in close 
huts or barracks, the disease frequently breaks out. 

When typhus fever appears in a community, those classes 
of the people who are subjected to the conditions just mentioned' 
are almost exclusively attacked. In cities, the dwellers in 
crowded tenements, or in courts and alleys, suffer most severely — 
are, in fact, almost the only ones attacked. An exception must, 
however, be made in the case of hospital physicians and attend- 



364 TEXT-BOOK OF HYGIENE. 

ants where typhus-fever patients are treated. The mortality 
among- these is always large. 

Typhus fever is contagious and infectious. An exposure 
for a length of time to an atmosphere impregnated with the 
poison may suffice to induce an attack. The poison may also 
be conveyed from place to place in fomites. Physicians may 
carry it in their clothing, if they have been exposed to a typhus 
atmosphere. 

The prevention of typhus fever consists in the institution of 
such measures as will secure pure air, pure water, a clean soil 
and dwellings, and cleanliness of body and clothing. When an 
outbreak occurs, the sick should be promptly isolated, the well 
persons removed from the building in which the cases have 
occurred, and efficient measures of disinfection carried out. The 
sick should be treated in the open air as much as possible. 

YELLOW FEYER. 

The West India Islands, the Gulf coast of Mexico, the 
northern part of the Atlantic coast of South America, and a 
limited section of the west coast of Africa constitute the present 
home of yellow fever. From this area (the so-called " yellow- 
fever zone ") the disease is frequently transported to contiguous 
or distant countries. The South Atlantic and Gulf coasts of the 
United States and the shores of the Caribbean Sea are most 
liable to the epidemic visitation of this pestilence. 

The first trustworthy account of an epidemic of yellow 
fever dates from the year 1635, when it prevailed on the Island 
of Guadeloupe. This and the adjoining islands of Dominica, 
Martinique, and Barbadoes were invaded a number of times in 
the fifty years following the above date. Jamaica was invaded 
in 1655 and Domingo the year after. In 1693 the first appear- 
ance of the disease is mentioned in the United States, being 
observed in Boston, Philadelphia, and Charleston. In 1699 it 
appeared as an epidemic in Vera Cruz, and re-appeared in Phila- 
delphia and Charleston. Since the year 1700, the disease has 



YELLOW FEVER. 365 

appeared in an epidemic form, at one or more places within the 
present limits of the United States, eighty times, the last consid- 
erable invasion being at Jacksonville and other places in Florida, 
and Decatur in Alabama, in 1888. 

In South America yellow fever appeared for the first time 
in 1740. In 1849 the disease was imported into Brazil, and 
has since then been endemic. Peru and the Argentine Republic 
have also suffered several severe visitations of yellow fever since 
1854. 

On the west coast of Africa, yellow fever seems to be en- 
demic in the peninsula of Sierra Leone, where it has been fre- 
quently observed since 1816. It has also prevailed epidemically 
in Senegambia and a number of the islands off the northern 
portion of the west African coast. In Europe, Spain and Por- 
tugal have been the only countries to suffer from yellow-fever 
epidemics. 

Although the causes of yellow fever cannot be definitely 
stated, it is well-known that it only occurs endemically within 
the tropics, and prevails epidemically elsewhere only during the 
summer. Of 180 epidemics observed in the United States and 
Bermudas, 154 began in July, August, and September. Of the 
remaining 26, none began in the six months from November to 
April. 

A temperature of 26° C. and a high humidity are gener- 
ally considered essential to produce an outbreak of the disease. 
Of other necessary meteorological conditions nothing is known. 

That the specific cause of yellow fever is a micro-organism 
appears probable from a consideration of the clinical history of 
the disease and its mode of propagation. Up to the present 
time, however, none of the various organisms described as causa- 
tive have made good the claims advanced by their discoverers. 
Surgeon-General Sternberg has shown that neither the organism 
of Freire, of Carmona, of Babes, of F. S. Billings, of Finlay, 
or of Gibier is the true cause of vellow fever. 

It seems to be well established that the most filthv and 



366 TEXT-BOOK OF HYGIENE. 

insanitary portions of cities are those principally ravaged by 
yellow fever. The author is convinced from personal observa- 
tion in Savannah, Memphis, and New Orleans, that filth is one 
of the principal factors in the spread of yellow fever. This 
opinion is also forcibly expressed by many of the most eminent 
authorities on the subject. 

Yellow fever is not endemic within the limits of the United 
States, and has probably never originated here. The instances 
in which it has appeared to do so may be explained by the per- 
sistence of the morbific agent through one or more winters, or 
by a new importation which has escaped observation. 

Yellow fever frequently breaks out on shipboard and causes 
much loss of life. There is no evidence that it originates on 
ships ; it is only acquired after intercourse with an infected ship 
or infected place. 

The question of the personal contagion of yellow fever has 
been decided negatively. The disease is infectious and its cause 
may be transported in fomites, but persons sick with the disease 
do not communicate it. An infected atmosphere, or one favor- 
able to the poison, is necessary to the propagation of the disease. 

The preventive measures indicated against yellow fever 
appear from the foregoing: they are strict sanitary inspection to 
prevent the introduction of a person sick with the disease; to 
prevent the introduction of clothing or other fomites from a 
suspected locality without thorough disinfection, and such a con- 
dition of public and private sanitation as will prevent the devel- 
opment of the poison, should the latter, perchance, be introduced. 

When the disease becomes epidemic in a city, the inhabi- 
tants should be removed to temporary camps beyond the infected 
area. The experience of the city of Memphis in 1879, and of 
various localities in Florida in 1888, encourages the hope that 
by prompt depopulation of cities and strict enforcement of sani- 
tary measures in the camps the terrors of yellow fever can be 
largely averted. The sick should be promptly isolated, and no 
one except attendants permitted to have intercourse with them, 



SCARLET FEVER AND MEASLES. 367 

SCARLET FEYER AND MEASLES. 

The early history of these two contagious eruptive fevers is 
inextricably blended together. Up to the latter half of the 
seventeenth century the distinction between the two was not 
made by writers. Sydenham was among the first who clearly 
separated scarlet fever from measles and gave it a distinct name. 
Since the great English Hippocrates, the essential character of 
scarlet fever has been recognized by all physicians, and it is now 
never, or but rarely, confounded with measles. 

Of the two diseases, measles is somewhat more generally 
prevalent, although both occur usually in epidemics. There is 
hardly a country in which measles has not been observed, while 
the continents of Asia and Africa have remained measurably 
exempt from scarlet fever up to the present time, although epi- 
demics have been recorded in India and Japan. 

Hirsch states that scarlet fever was first observed in this 
country in 1735, at Kingston, Mass., quoting as authorities Dr. 
Douglass, of Boston, and Dr. Colden, of New York. The 
latter, however, in a letter to Dr. Fothergill, 1 clearly describes 
diphtheria, and not scarlet fever. Its distribution is now general, 
but it is said to be much milder in the southern than in other 
portions of the United States. The prevalence of measles is not 
limited to any geographical section. 

Epidemics of measles usually begin during cold weather. 
Of 530 epidemics observed in Europe and North America, 339 
occurred during the colder and 191 during the warmer months. 
In 213 of these, the height of the epidemic occurred 135 times 
in winter and spring, and only 78 times during summer and 
autumn. Scarlet fever epidemics occur more frequently in 
autumn than at any other season. 

The cause of scarlet fever or of measles is not to be 
sought in climatic influences, insanitary surroundings, or special 
natural conditions of air, water, or soil. Both diseases are 
contagious and infectious, and the contagion is transmitted either 

1 Medical Observations and Inquiries, vol, i, p. 211, London, 1776, 



368 TEXT-BOOK OF HYGIENE. 

by fomites (clothing, letters, etc.), infected air, drinking-water, 
or milk. 

Several observers have claimed the discovery of the specific 
organism of scarlet fever, but no trustworthy evidence has yet 
been furnished that the problem is solved. On a previous page 
(93) reference has been made to the probable connection between 
a disease of milk-cattle and scarlet fever. 

The measures for the prevention of both diseases are isola- 
tion and thorough disinfection. 

DIPHTHERIA. 

Under the names of Syriac and Egyptian ulcers, Aretewus, 
a writer of the second century, described various forms of malig- 
nant sore throat. The disease now called diphtheria prevailed at 
various places in Europe during the Middle Ages. In this country 
it was first observed about the middle of the last century, and 
in 1771 Dr. Samuel Bard, of New York, described it very 
accurately. Although repeated severe outbreaks occurred in 
Europe in the early part of the present century, it was not until 
1857 that it again attracted attention by its epidemic prevalence 
in the United States. Since that time it has spread throughout 
the country, and is at present one of the most generally diffused, 
as well as one of the most fatal, of the contagious diseases. In 
certain epidemics its malignancy is very marked, while in others 
it seems to be a rather mild affection. 

Diphtheria is personally contagious ; it may be transmitted 
by inoculation, as well as by inhaling an infected atmosphere. 
The infecting agent is most probably the micro-organism first 
described by Lofner. The bacillus cannot always be demon- 
strated, and is, further, likely to be confounded with non-patho- 
genic organisms possessing similar morphological characters. 

The question as to the identity of diphtheria and croup is 
not merely a clinical one, but has an important bearing upon 
preventive medicine. If croup is a non-contagious and non- 
infectious disease, as is held by many, no precautions will be 



DENGUE. 369 

necessary to prevent its spread to healthy persons. If, on the 
other hand, diphtheria and croup are identical in nature, the 
danger of infection is equally great in both diseases. Inasmuch 
as it is frequently impossible to positively decide upon a diagnosis, 
it would be well to consider the identity of the two diseases as 
established, and act, as far as preventive measures are concerned, 
as if all were cases of diphtheria. 

Diphtheria is inoculable upon animals, and may through 
this medium be transmitted to man. 

Persons sick with diphtheria should be carefully isolated ; 
no one but the immediate attendants should be allowed to come 
in contact with the patients. Table utensils, bedding, and cloth- 
ing used by the sick should be thoroughly disinfected by steam 
or boiling water before being used by others. Intimate contact 
with the sick, such as kissing, should be strictly prohibited. 
There seems no room to doubt that the virus of the disease can 
also be carried in the clothing. Hence, physicians and nurses 
should be especially careful in personally disinfecting themselves 
after contact with a case of diphtheria. After death or recovery 
of the patient, the apartment occupied during the illness should 
be disinfected with chlorine or sulphurous-acid gas. 

Children recovering from diphtheria, scarlet fever, measles, 
or small-pox, should not be permitted to attend school for at 
least four weeks after recovery. It is believed that there is 
danger of infection for a period about as long as this, and, besides, 
the patients are apt to be weakened from the effects of the dis- 
ease, and not able to resist the strain of continuous mental effort. 

DENGUE. 

The disease known as break-bone fever, dandy fever, and 
by various other names, was first observed in the United States 
in 1780 by Dr. Benjamin Rush. Dr. Rush describes an epi- 
demic which prevailed during the summer and early autumn of 
that year under the name of " bilious remittent fever," but the 
symptoms of the disease hardly leave any doubt that it was 

24 



370 TEXT-BOOK OF HYGIENE. 

dengue. In 1779 and 1780 it was also observed on the Coro- 
mandel coast, in Egypt, and on the island of Java. In 1784 to 
1788 dengue also prevailed in various cities of Spain. In 1818 
an epidemic appeared in Lima, in which nearly every one of the 
70,000 inhabitants was attacked. 

In 1824-25 the disease again prevailed widely in India, 
where it was known as the " three-day fever." Isolated out- 
breaks occurred in that country until 1853, when it again ap- 
peared as a wide-spread epidemic, and in 1872 another epidemic 
outbreak occurred in the East, extending from Eastern Africa 
to Arabia, India, and China. 

In 1826 an epidemic of dengue appeared in Savannah, and 
in the following two years spread over the southern portion of 
the United States and the West Indies, reaching the northern 
coast of South America. In 1845 to 1849 the disease was 
observed in Rio Janeiro; in 1848 to 1850 in the South Atlantic 
and Gulf States. In 1854 it was observed in Southern Alabama, 
and in the same year in the West Indies. In 1873 another 
epidemic appeared in the lower Mississippi Valley, and in 
1880 an outbreak of some extent occurred in New Orleans, 
Charleston, and other places on the Gulf and South Atlantic 
coasts. 

Dengue always begins in the summer or early autumn, and 
ceases abruptly with the advent of cold weather. It is almost 
exclusively limited to hot countries. It spreads with extreme 
rapidity wherever it appears. It is not contagious ; the man- 
ner of its propagation is not known. The susceptibility to the 
disease appears to be almost universal ; it frequently prostrates 
the majority of the inhabitants where an outbreak occurs. 
During the epidemic in Calcutta in 1871-72, 75 per cent, of the 
population were attacked. In the United States similar epi- 
demics have been repeatedly observed. 

Dengue is rarely fatal. It seems to be propagated through 
the atmosphere. No measures of prevention are known or 
available. 



EPIDEMIC INFLUENZA. 371 

EPIDEMIC INFLUENZA. 

Accounts of epidemic influenza can be traced back to the 
year 1173, when the disease was observed coincidently in Italy, 
Germany, and England. It has prevailed epidemically, at vary- 
ing intervals, to the present time. In the fourteenth century 
3 epidemics are recorded ; in the fifteenth, 4 ; in the sixteenth, 
7 ; in the seventeenth, 46. Of these, 15 were very extensive, 
some of them prevailing over both hemispheres contempo- 
raneously. 

On the American continent influenza was first recorded in 
1627, when it prevailed in New England, where it again broke 
out in 1625. Following this there is no notice of the disease 
in America until 1732, when an epidemic began in the New 
England States, which extended over the entire globe. Epi- 
demics occurred during the remainder of the eighteenth cen- 
tury in 1737, 1757, 1761, 1767, 1772, 1781, 1789, and 1798. 
During the present century the disease has prevailed more or 
less extensively in this country at thirteen different times, the 
last epidemic of any considerable extent being in 1879. 

In November, 1889, an epidemic began in Russia which 
rapidly spread throughout Northern Europe, reaching the United 
States about the beginning of 1890, recurring in 1891 and 1892. 
The epidemic was complicated in many cases by pneumonia of a 
fatal character. The disease manifested itself in two principal 
forms, the catarrhal and the nervous. Weichselbaum, of Vienna, 
claims to have discovered a micro-organism which he believes to be 
the cause of the affection, but this claim has not yet been verified. 

A curious feature of epidemics of influenza is the coinci- 
dent occurrence of outbreaks of a somewhat similar affection 
among animals, horses and dogs being especially attacked. 

Influenza is an acute, specific, infectious disease, not di- 
rectly contagious. The infection is apparently produced or trans- 
mitted in the air. The disease frequently appears over a large 
area of country almost simultaneously. Peculiarities of climate, 
season, meteorological conditions, geological formation, or racial 



372 TEXT-BOOK OF HYGIENE. 

characteristics have no apparent influence upon the causation or 
spread of the disease. It occurs more frequently in the winter 
and spring- than during the summer or autumnal months. The 
investigation into the epidemic of influenza among horses, re- 
ferred to in a previous chapter, 1 seems to indicate, however, that a 
moist and impure atmosphere intensifies the disease. 

No measures of prophylaxis can be indicated except avoid- 
ance of anything tending to depress the vital powers. 

EPIDEMIC CEREBRO-SPINAL MENINGITIS. 

This disease was first recognized in Geneva in 1805. In 
the following year it was noted in various places in the United 
States. Both in Europe and this country localized outbreaks 
of the disease occurred between the dates above mentioned and 
1816. At this time the disease seemed to die out altogether, 
but in 1822 it re-appeared in various parts of Europe and 
America. 

Cerebro-spinal meningitis appeared in 1857 in the south- 
west of France, and during the following ten years spread over 
a large part of the country. Algiers, Italy, Denmark, and Ire- 
land were also visited by the scourge. In 1854 and 1861 
Sweden experienced its ravages, and in 1859 Norway was 
invaded by the disease, which continued for nearly a decennium 
in the latter country. From 1860 to 1867 the disease prevailed 
in Holland, Portugal, Germany, Ireland, and Russia. 

After the termination of what may be called the first epi- 
demic, in 1816, cerebro-spinal meningitis was not again observed 
in this country until 1842. In the eight years succeeding, it 
prevailed epidemically throughout almost the whole United 
States. From 1861 to 1873 it was noted frequently in various 
parts of the country. Since the latter year the reports of its 
occurrence in this country have been limited to sporadic cases 
or localized outbreaks. 

Cerebro-spinal meningitis is an acute infectious disease, 

1 Chapter I, p. 29. 



SYPHILIS. 373 

very fatal in its tendency. It is probably not personally con- 
tagions. Climate has no influence upon its origin, but season 
seems to stand in a positive relation to its causation. About 
three-fourths of the epidemics noticed have occurred during the 
winter and spring months. The disease seems to show no 
preference for peculiarities of topographical or geographical 
formation. Overcrowding, overwork, and uncleanliness have 
an important influence in determining an outbreak. It is 
especially a disease of youth and adolescence. Out of 975 
cases occurring in New York only 150 were over 20 years of 
age, while of the remainder 665 were under 10. 

The prophylactic measures to be adopted against cerebro- 
spinal meningitis consist in careful attention to the sanitary 
conditions of dwellings and streets, avoidance of overwork and 
overcrowding during times of epidemic, isolation of the sick, 
and disinfection of the sick-room after the termination of the 
disease. 

SYPHILIS. 

In the year 1494, Charles VIII, of France, in command of 
a large army invaded Italy, and early in the following year be- 
sieged Naples. During the investment of the city a very severe 
disease, characterized by ulcers of the genitals, violent pains in 
the head and limbs, and generalized cutaneous eruptions broke 
out among the besiegers and spread rapidly throughout the 
army and civil population. On the return of the army to France, 
after the termination of the war, the disease rapidly spread 
throughout Europe, and the literature of the early part of the 
sixteenth century, both medical and lay, teems with references 
to it. 

From the locality and other circumstances connected with 
its epidemic appearance the disease acquired various names. 
Thus, the French called it morbus Neapolitanus, or mal d'ltalie, 
while the Italians termed it morbus Gallicus, or mala Franzos. 
At a very early period it was, however, clearly recognized that 
the disease was communicated during sexual intercourse, and 



o74 TEXT-BOOK OF HYGIENE. 

hence it was usually described in medical writings under the 
name lues venerea, while in the popular literature it still figured 
as the Frenchman's disease (morbus Gallicus). The name syphilis 
was first used in a poem descriptive of the disease, written in 
1521 by Fracastor, a physician of Verona. 

The extraordinary outbreak of the disease toward the end 
of the fifteenth century led to many speculations concerning its 
origin. As it attacked persons in all ranks and conditions of 
life, " sparing neither crown nor cross," in the words of a con- 
temporary poet, the favorite explanation was that meteorological 
influences had much to do with its causation. Many ascribed 
it to the malign influence of the stars. The Neapolitans attrib- 
uted it to the wickedness of their enemies, the French, while 
the latter laid the blame on the filth and immorality of the 
Italians. The Spaniards claimed that it had been imported from 
America by Columbus, whose first expedition returned to Europe 
in 1493. There are records, however, which prove that the dis- 
ease already existed in Italy in the latter year. In other parts 
of Europe the Jews, who had been driven out of Spain by the 
terrors of the Inquisition, were accused of this, as of many other 
misfortunes which befell the people. When it was definitely 
established that the disease was communicated almost solely by 
sexual intercourse, the theory of its transatlantic origin became 
very popular. It is characteristic of human nature to refer 
the origin of troubles resulting from its own vices to some other 
source, if possible. This theory of the American origin of 
syphilis is still held by some writers. Within a few years, Dr. 
Joseph Jones, of New Orleans, claims to have found evidences 
of syphilitic disease in the skulls and other bones from some of 
the prehistoric Indian mounds in Mississippi. These observa- 
tions of Dr. Jones have, however, not yet been verified by others. 

Although the first great epidemic of syphilis is clearly trace- 
able to the period between the years 1493 and 1496, an ex- 
amination of the older literature reveals many descriptions of 
disease which can only be explained by assuming them to refer 



SYPHILIS. 375 

to syphilis. The Old Testament Scriptures contain numerous 
references to diseases of the genital organs. In most instances 
these troubles are ascribed to the wrath of God, although in 
some cases a pretty shrewd hint is given as to the causation of 
the affections. Finaly 1 remarks that the Hebrew word trans- 
lated in all versions of the Bible by " flesh'' signifies also the 
virile member. In this light, the references in Leviticus, XIII- 
XV; Numbers, XXV, 1-9, XXXI, 16-18; Deuteronomy, IV, 3; 
Joshua, XXII, 17 ; I Samuel, V, 6, 9, 12 ; Psalms, CVI, 28-30 ; 
I Corinthians, X, 8; Ephesians, II, 11 ; and Colossians, II, 13, 
receive a new interpretation. Numerous innuendoes in the 
Latin classics, and more or less exact descriptions in the medical 
writings of Greece, Rome, China, and India, leave no room for 
doubt that venereal diseases, and probably among them syphilis, 
have existed from the earliest times. 

At the present day syphilis is the most widely prevalent of 
all contagious diseases. In 1873 Dr. F. R. Sturgis estimated 
that in New York 1 person out of every 18 suffered from it. 
This is considered a moderate estimate. Dr. J. Wm. White, 
of Philadelphia, pronounces the opinion that "not less than 
50,000 people of all classes in that city are affected with syphilis." 
On this basis Gihon estimates the number of syphilitics in the 
United States at one time at 2,000,000. 2 

The disease is transmitted, in the vast majority of cases, 
during the performance of the sexual act, but there are numerous 
other ways in which it may be and frequently is communicated. 
In the special literature of the subject are records of many cases 
in which the disease was acquired through a kiss, a bite, the act 
of suckling (from infant to nurse, and conversely), using a pipe, 
glass-blowers' mouth-piece, the finger of a midwife, the instru- 
ments of the dentist or surgeon, inoculation of syphilitic secretion 
mixed with saliva in the process of tattooing, and many other 
ways. Numerous cases have been reported where physicians were 
inoculated on the finger while examining a syphilitic patient. 

1 Arch. f. Dermat. u. Syphilis, II Jahrg. 1 Heft., p. 126. 

* The Prevention of Venereal Diseases by Legislation, Sanitarian, June, 1882. 



376 TEXT-BOOK OF HYGIENE. 

The prophylactic measures which suggest themselves from 
a consideration of the nature of the disease are isolation of those 
infected, regular inspection of the class of persons through whom 
the disease is most frequently transmitted, i.e., prostitutes, and 
individual precautions against acquiring it. Greater attention 
to cleanliness of the genital organs on the part of those indulg- 
ing in promiscuous intercourse would aid largely in reducing 
the number of cases of syphilis. 

DISEASES OF ANIMALS COMMUNICABLE TO MAN. 

Sheep-poclc. — This is a highly contagious and infectious 
disease of sheep, resembling, in its symptoms, course, and fatality, 
small-pox as it occurs in the human race. It is believed by 
Bollinger to be different from the form of small-pox produced 
in sheep, goats, horses, and other animals by the inoculation of 
Human small-pox. Sheep-pock can be inoculated upon other 
animals and man, but only produces a local disease at the point 
of inoculation in the latter. Sheep may be protected against 
this disease by inoculation with sheep-pock virus (ovination), or 
by vaccination with vaccine lymph. The peculiarity of sheep 
vaccinia is that it is a more or less generalized disease, the 
pustules being distributed over the body. Sheep-pock, when 
inoculated upon human beings, does not produce a generalized 
infectious disease, but remains entirely local. 

Actinomycosis. — Veterinarians have frequently observed a 
disease attacking the jaws of cattle and producing tumors, often 
with ulcerated surfaces. The bone is usually involved. The 
disease has heretofore been generally considered a sarcomatous 
growth. It is not seldom observed among the cattle in the 
western stockyards, where it is known in the vernacular as 
" swell-head." Recent investigations by Ponfick have shown 
that the growth consists of a vegetable parasite (actinomyces), 
and that it is inoculable upon other animals, and may be 
conveyed to man. A considerable number of cases have been 
observed in human beings in Germany, where the disease was 



DISEASES OF ANIMALS COMMUNICABLE TO MAN. 377 

first described by Ponfick, and very recently 4 cases have 
been reported in this country. 1 

Bovine Tuberculosis (Perlsucht). — In cattle, tuberculosis 
occurs in two forms, miliary tubercles and cheesy masses in the 
lungs, and firm, pearly nodules on the serous membranes. 
These nodules do not break down, but may become calcified. 

Bovine tuberculosis is a frequent disease among cows kept 
in damp, dark, and ill-ventilated stables. The disease, which is 
essentially the same as human tuberculosis, tubercle bacilli 
being present in the neoplasms, is believed by many to be trans- 
missible to human beings by means of the milk or flesh of 
tuberculous animals. The sale of the meat of tuberculous cattle 
should be prohibited. 

Rabies. — Hydrophobia in the brute, and its communi- 
cability to man through a bite, has been known from the 
remotest antiquity. It occurs in dogs, foxes, wolves, horses, 
and other animals, and may be transmitted from any of them to 
human beings. 

The contagium of rabies, the infective poison, is contained 
principally in the saliva, and is usually inoculated by the teeth 
of the mad animal. 

Pasteur has shown that the greatest virulence of the rabies 
poison resides in the brain and spinal cord of the animal suffer- 
ing from the disease. By cultivation of this virus, the nature 
of which has not yet been definitely determined, its virulence 
could be diminished, and by inoculation of men and animals 
with the attenuated virus protection against the disease could 
be secured. The fact seems likewise established that the period 
of incubation of the inoculation-rabies is much shorter than that 
acquired in the usual way by bites of rabid animals. Hence, 
inoculation with the attenuated virus protects the bitten individ- 
ual against the fatal outbreak of the unmodified disease. 

Anthrax. — Anthrax, or splenic fever (milzbrand), is an 

1 Boston Med. and Surg. Journal, Oct. 16, 1884, p. 377, and Journ. Am. Med. Ass'n, Nov. 27, 
1886. Also, N. E. Med. Monthly, Sept. 15, 1886. 



378 TEXT-BOOK OF HYGIENE. 

acute, highly contagious and infectious disease of herbivorous 
animals, which may be transmitted by inoculation or the 
ingestion of the virus to other animals and to man. 

The disease is due to a minute vegetable organism which 
is found in the blood and tissues of the diseased animals. This 
organism, bacillus anthracis, was first discovered by Pollender, 
and has been thoroughly investigated by Davaine, Pasteur, 
Koch, and others. 

Inoculation of these bacilli or their spores always produces 
the disease in susceptible animals. Skins of animals not infre- 
quently contain the virus, which may then gain access to the 
blood of persons engaged in handling them. Knackers, 
butchers, wool-sorters, and other persons liable to come in 
contact with sick animals, or handling their flesh or hides, are 
subject to the infection, either by direct inoculation (through 
abrasions of the skin, etc.) or by inhalation of the spores of the 
bacillus. An intestinal form of anthrax in man, mycosis intes- 
tinalis, is sometimes produced by the consumption of meat of 
animals suffering, when killed, of splenic fever. Numerous 
instances have been reported. The diagnosis has been verified 
by discovering the bacillus of anthrax in the blood and various 
organs of the individuals attacked. 

In view of the dangerous character of the disease, persons 
coming in contact with animals suffering from anthrax should 
be warned of their peril. In order to protect other animals in 
a herd, strict isolation of the infected, thorough disinfection of 
the stables occupied by them, and deep interment of the cadavers 
of those dead from the disease are indicated. 

Glanders. — Glanders, or farcy, is a very fatal contagious 
disease of horses which may be communicated to other animals 
and to man. The cause of glanders has recently been discovered 
by Lofrler to be a bacillus resembling the bacillus tuberculosis. 
Pure cultures of this bacillus were inoculated into animals, and 
followed by glanders in a number of the cases. 

The infection in man may occur either upon the seat of 



DISEASES OF ANIMALS COMMUNICABLE TO MAN. 379 

excoriations of the skin or mucous membranes, especially those 
of the nose, conjunctiva, and possibly by inhalation of infective 
particles floating in the air. 

Animals with glanders should be promptly killed and their 
cadavers cremated or deeply buried. No part of the body of 
any animal dead with glanders should be allowed to be used. 
Infected stables should be thoroughly disinfected. 

[The works of especial value to students who desire fuller 
information upon the subjects treated in this chapter are the 
following : — 

Hirsch, Handbuch der Historisch-Geographischen Pathologie, 2te 
Aufl., Stuttgart, 1883. — Hseser, Geschichteder Epidemiscben Krankbeiten. 
— Hecker, The Black Death, translated by B. G. Babington. — Rohlfs, 
Die Orientalische Pest. — Marson, " Small-pox," in Re3*nolds's System of 
Medicine, vol. i. — Seaton, " Vaccination," ibid. — Trousseau, Clinical Medi- 
cine, vol, i. — Fifth Annual Report of Illinois State Board of Health. — 
Hardaway, Essentials of Vaccination. — Crookshank, History and Pathol- 
og}' of Vaccination. — Wood worth and McClellan, Cholera Epidemic in 
United States in 18*73. — Chaille, "Report of Yellow Fever Commission," 
Annual Report National Board of Health for 1880. — Wood and Formad, 
" Memoir on the Nature of Diphtheria," ibid., 1882. — Thompson, Annals of 
Influenza. — Stille, Epidemic Meningitis. — Mueller, Die Venerischen 
Krankbeiten im Altherthuin. — Lancereaux, Traite de la Syphilis. — 
Bollinger, " Ueber Menschen u. Thierpocken," etc.-, Samml. klin. Vortr., 
No. 116. — Ponfick, Die Actinomycose des Menschen. — Gamgee, u Hydro- 
phobia and Glanders," in Reynolds's System of Medicine, vol. i. — 
Bollinger, " Anthrax," in Ziemssen's C}'Clop8edia, vol. iii. — E. 0. Shakes- 
peare, Report on Cholera in Europe. — Surgeon-General G. M. Stern- 
berg, Etiology and Prevention of Yellow Fever. — Ernest Hart, " Water- 
borne Cholera," Journ. Am. Med. Ass'n, July 1. 1893.] 



QUESTIONS TO CHAPTER XIX. 

History of Epidemic Diseases. 

Of what advantage is the study of the history of epidemic dis- 
eases ? What are some of the most important maladies of this class ? 
To what are they all due ? 

What are some of the synonyms of the Oriental plague? What 
are some of its characteristic symptoms ? What is the elate of the first 
clear account of it ? How long did this epidemic persist ? When did it 
make its second incursion into Europe ? What was one of the peculiar 
symptoms of this epidemic? What was its estimated mortality ? What 
were some of its moral effects? When was its final incursion into 
Western Europe? What minor epidemics of it have there been since? 
When was the last, and where ? Is it now endemic anywhere ? To 
what was' its origin formerly ascribed ? What conditions are always 
present when the plague prevails ? What is another evident factor in 
its causation ? How is it generally transmitted ? Is it a germ disease ? 
What are the measures of prevention therefore indicated ? 

What is the sweating sickness ? What are some of its character- 
istic symptoms and peculiarities? What is evidently its nature? Is 
there any class exempt from it ? What favors its spread ? What rela- 
tion has it to cholera? When did it first appear in England ? When for 
the last time? Where has it appeared since? Have there been many 
outbreaks in Europe ? 

What are the earliest details regarding small-pox ? When was it 
supposed to have been introduced into Europe? Who made the first 
distinct reference to it in medical literature ? When ? What was the 
estimated mortality from this disease in Europe previous to the intro- 
duction of vaccination ? Where has it been very fatal in its devastations 
in recent years? What other countries and peoples have suffered from 
it ? What is the mortality from unmodified small-pox ? How is the dis- 
ease transmitted? What factors are necessary to cause an outbreak? 
What may carry the poison? For what distance about a patient may 
the air be infectious? In what stages of the disease is it contagious? 
What races are more commonly attacked, and among which is it more 
fatal ? 

Does one attack of small-pox always confer future immunity from 

(380) 



QUESTIONS TO CHAPTER XIX. 381 

the disease ? Wherein is the popular belief, that persons suffering from an 
acute or chronic disease are less liable to incur small-pox than the healthy, 
at fault ? Which maladies are most likely to afford this immunity ? When 
does such immunity appear to cease ? 

When do epidemics of small-pox usually begin ? In what seasons do 
they spread most rapidly ? Does the disease spread rapidly at first ? 
Has the specific organism of small-pox been certainly discovered ? 

When was the first attempt to limit the fatality of small-pox by in- 
oculation made in Europe? When was the practice introduced into 
England, and by whom ? What were the details of the method as then 
practiced ? What were the characteristics of the disease thus produced? 
Was the practice altogether without danger to the one inoculated ? 
What other grave objection was there to such inoculations ? When was 
the practice of inoculation introduced into America, and by whom ? 
How long was it continued in England and in America? Where was it 
practiced before its introduction into Europe? 

What led to the discovery of vaccination ? Who first practiced it ? 
When ? To whom is due the merit of demonstrating and publishing 
the value of vaccination ? When did he perform his first vaccination, 
and with what results ? When did he publish the first pamphlet in rela- 
tion to it ? When was vaccination introduced into America, and by 
whom? 

What is the relation of vaccinia (cow-pox) to small-pox ? What are 
the S3^mptoms produced in the case of a successful vaccination ? When 
may the individual be considered to be thoroughly protected? Is 
the immunity absolute for life? What is the character of an attack 
of small-pox in an individual who has once been vaccinated ? Does 
repeated vaccination increase the immunity ? What effect has vaccina- 
tion had on the mortality from small-pox ? On the prevalence of the 
disease ? 

What important precaution should be observed in all vaccinations ? 
Why ? When should children be vaccinated ? When should the}^ be re- 
vaccinated ? What are some of the peculiarities following upon revacci- 
nation ? What are some of the objections urged against humanized 
virus ? Are these all valid ? What are some of its advantages ? How 
is it to be inoculated ? How is animal virus obtained ? How is it to be 
used ? In what way do the results from using it differ from those of 
humanized virus ? 

What complications are likely to occur in the course of the vaccinia ? 
What are some of the causes of these complications ? What subjects are 
unfavorable ones for vaccination ? When may vaccination be properly 



382 QUESTIONS TO CHAPTER XIX. 

delayed ? What diseases may be communicated by or may follow vacci- 
nation ? What cases should be promptly revaccinated. 

What besides vaccination is highly important in the prophylaxis of 
small-pox ? What precautions should be observed in the care of one sick 
with small-pox ? What are the best disinfectants for such cases ? When 
is all danger of infection over ? 

Where is Asiatic cholera endemic ? What can be said of its ravages 
there ? When were the first authentic accounts of it given ? When did 
the disease first become epidemic outside of India? What were some of 
the countries visited ? When did it first appear in England ? When 
and where in America ? When did this outbreak from India end ? When 
did it again become pandemic, and how long before it again reached the 
United States? What were the ports through which it entered ? How 
long did it persist in this country ? How long in South America ? When 
was the next visitation to this country ? What parts of South America 
were first invaded at this time ? Where else was cholera raging during 
these periods, and where was it practically endemic ? 

When was the last serious importation of the disease into this country, 
and by what port did it enter ? Where else, and when, have there been 
important epidemics since this date ? What does the history of all these 
epidemics demonstrate ? What factors must concur that there may be 
an epidemic? What is the specific cause of cholera? Who discovered 
it? When ? Is the disease contagions? How is it spread? What con- 
ditions seem to be necessary for its propagation? When do outbreaks 
usually occur, and when do they subside ? Why is the disease endemic in 
India? How do these conditions predispose the victims to the disease? 
Are these conditions peculiar to India? Where else may they exist ? 

How is the specific organism given off from the human body ? How 
does it usually gain entrance into others ? What evidence is there 
of this (see chapter on Water) ? What other agencies may aid in 
disseminating the disease? 

What are the measures of prophylaxis against cholera ? How can 
the entrance of the disease into a community be prevented? What 
measures of local sanitation may be even more effective ? Why ? How 
shall the drinking-water and food be rendered harmless ? 

How may one guard against an individual predisposition to cholera ? 
What measure of personal prophylaxis is useful ? What is the rationale 
of this? What disease may simulate cholera during an epidemic, and 
to what is it often due ? 

In times of cholera epidemics, what sanitary measures are to be es- 
tablished ? What disinfectants are to be used ? What articles are to be 



QUESTIONS TO CHAPTER XIX. 383 

disinfected, and how? What are some of the objections to the indis- 
criminate use of the bichloride of mercury ? What may be used in its 
stead ? What does Koch recommend, and what objection is there to its 
use ? What plan should be pursued at the beginning of an epidemic ? 

When was relapsing fever first described ? When was it first 
observed in America ? When did it last appear here ? What predis- 
posing conditions favor it ? What is its specific exciting cause ? Where 
is the germ found ? What are the preventive measures to be used against 
relapsing fever ? 

How long has typhoid fever been known as a distinct disease? 
Where is typhoid fever common ? When is it most prevalent ? What 
persons and ages are most subject to it? To what is the disease due? 
Where is it found ? Is the disease contagious ? Where is the poison 
developed ? Does it arise de novo? How may the poison be conveyed 
to human beings ? What prophylaxis may be employed against t} r phoid 
fever ? What are the requisites for prevention ? 

When were the earliest authentic accounts of tj'phus fever made ? 
What predisposing conditions favor its development and spread ? When 
is it more prevalent ? By what is it limited ? Where is it apt to occur ? 
What class of persons is most likely to be attacked ? Is it contagious ? 
How may it be prevented ? What measures are to be pursued during an 
outbreak of the disease ? 

Where is the present home of yellow fever? What localities are 
most liable to epidemics of this disease ? What is the date of the first 
authentic account of it ? When and where did it first appear in the 
United States ? Has it ever originated here or been endemic ? How 
many times has it been epidemic in this country in the last two centuries ? 
When and where was the last epidemic ? In what season do epidemics 
occur? In what climates may it be endemic ? What climatic conditions 
seem to be necessary for an outbreak ? What is probably its specific 
cause ? Has this been discovered ? What is one of the principal factors 
in its spread ? Is the disease contagious ? How is the poison conveyed ? 
What is necessary to the propagation of the disease ? What preventive 
measures are to be employed against yellow fever ? 

What is to be done, should the disease become epidemic in a city ? 
Will this be efficacious in most cases ? 

Who first distinguished between scarlet fever and measles ? Which 
disease is more prevalent ? What countries have been practically exempt 
from scarlet fever ? When was scarlet fever first observed in America ? 
When do epidemics of measles usually begin ? When of scarlet fever ? 
What is the exciting cause of each disease, and how may it be conveyed ? 



38-i QUESTIONS TO CHAPTER XIX. 

Have bad hygienic surroundings an influence in the propagation of either 
disease? What are measures for prevention in both cases? 

How old is the history of diphtheria? When was it first observed 
in this country? When did it again prevail epidemically here ? How 
are various epidemics marked? Is it contagious? How may it be con- 
veyed ? What is the exciting cause? Is diphtheria identical with croup? 
What plan should be pursued for prevention regarding the two diseases? 
Is diphtheria transmissible to animals? What precautions should be 
taken with a person sick with diphtheria ? How long should children 
who have had diphtheria, scarlet fever, small-pox, or measles be detained 
from school ? Whj T ? 

What is dengue ? When and b} T whom was it first observed in the 
United States ? When does an epidemic begin, and when does it stop ? 
To what countries is the disease limited ? Is it contagious ? How is it 
propagated? Who are susceptible? What are the measures of preven- 
tion that may be employed? Is the disease fatal? 

What is the date of the earliest accounts of epidemic influenza? 
What are some of its synonyms ? When did it first prevail in America? 
When was the last epidemic ? How was this one complicated ? Are ani- 
mals subject to this disease ? Is it contagious? How is it transmitted ? 
When is it most prevalent ? What are the measures of prophylaxis 
against it ? 

When was epidemic cerebro-spinal meningitis first recognized? 
When did it appear in America? When was the first epidemic here ? 
When the next ? When the last? Is it contagious or infectious? What 
is its tendency ? When is it most liable to occur? What influence has 
climate upon it? What factors seem to favor an outbreak ? What ages 
are most subject to it? What is the proplrylactic treatment? 

When and where does syphilis seem to have had its origin ? Are 
there any traces of evidence of its existence before this ? What can be 
said of its comparative prevalence ? How is it usually transmitted ? In 
what other ways ma}- it be conveyed ? What proplrylactic measures are 
indicated ? 

What are some of the serious diseases of animals communicable to 
man ? What is sheep-pock, and what is its peculiarity when inoculated 
upon human beings ? 

What is actinonrycosis ? What are some of the synonj T ms ? To 
what is it due ? 

In what two forms does tuberculosis occur in cattle? Is it common 
among them ? How is it related to human tuberculosis ? How may it be 



QUESTIONS TO CHAPTER XIX. 385 

transmitted to man? What precautions should be enforced to prevent 
this transmission? 

What is rabies ? How is it transmitted? Where is the contagium 
contained ? Where does the poison of greatest virulence reside ? How 
may the virus be cultivated, and what changes take place in it ? How 
ma} T immunity against the disease be produced ? Who discovered and 
advocated this method of inoculation? 

What is anthrax ? What are some of its s3'non3'ms ? To what 
is it due ? How may it be transmitted ? What are the measures of 
proplrylaxis against it, both for man and animals ? 

What is glanders ? To what is it due ? How may infection occur ? 
What should be done with animals sick with this disease ? What else 
should be done ? 

25 



CHAPTER XX. 

Antiseptics, Disinfectants, and Deodorants. 

Much confusion exists in the popular mind, and even 
among physicians, as to the exact meaning of the terms at the 
head of this chapter. By many they are used synonymously, and 
hence frequently give rise to ambiguity and misunderstanding. 

Antisepsis, which is so frequently confounded with disin- 
fection, should be more accurately denned than is usual by 
writers. An antiseptic is an agent which retards, prevents, or 
arrests putrefaction, decay, or fermentation. It does not neces- 
sarily destroy the vitality of the organisms upon which these 
processes depend. An antiseptic may also arrest the develop- 
ment of the organisms which cause infectious diseases, and may 
hence be used as a preventive of such diseases. But antiseptics 
do not destroy the life of disease-germs, and hence cannot be 
relied upon when such organisms are present. 

By disinfection, in the proper and restricted use of the term, 
is meant the destruction of the specific infectious material which 
causes infectious diseases. If the view is accepted that all in- 
fectious diseases are due to micro-organisms or germs, then a 
disinfectant is equivalent to a germicide. In sanitary practice 
and experimental investigations this view is, in fact, adopted. 
In testing the action of various disinfecting agents upon infec- 
tious material, the biological test is the one universally relied 
upon by experimenters, and no observations upon disinfection 
based upon chemical tests alone would be accepted by sanitarians 
as conclusive. It may therefore be assumed for practical pur- 
poses that no agent can be accepted as a disinfectant if it is not 
also a germicide. From this it follows that disinfection, to be 
trustworthy, must be thorough. "There can be no partial 
disinfection of infectious material ; either its infectious power is 
destroyed, or it is not. In the latter case there is a failure to 
disinfect. nl Obviously, also, there can be no disinfection in the 

1 Report of Committee on Disinfectants of the American Public Health Association j). 236. 

(387) 



388 



TEXT-BOOK OF HYGIENE. 



absence of infectious material. Faecal discharges, a diseased 
body or corpse, clothing, bedding, an apartment, a ship, or a 
hospital ward may or may not be infected. In the former case 
we may speak of disinfecting them ; in the latter, it would be an 
inappropriate use of the word. 

Confusion is also liable to arise by considering disinfectants 
and deodorizers as synonymous. Deodorants merely remove 
offensive odors, and may not possess any disinfecting power 
whatever. Thus, one of the most efficient disinfectants at our 
command (mercuric chloride) is not a deodorizer at all, except 
by preventing putrefaction. On the other hand, some of the 
most effective deodorants have only a subordinate position in the 
scale of disinfectants. 

Careful investigations have shown that there is a wide 
divergence between various disinfecting agents in their influence 
upon disease-germs, some being efficient in high dilutions, while 
others require to be brought in contact with the germs in great 
concentration. For example, mercuric chloride will act as an 
efficient poison to certain disease-germs (anthrax spores) in the 
proportion of 1 to 1000, while zinc-chloride must be used in the 
proportion of 1 to 5 (or 20 per cent.). 

It has been, further, discovered that different disease-germs 

present varying resisting power to the same disinfecting agent, 

some being easily destroyed, while others are much more resistant. 

For example, the following table shows a number of experiments 

made by Dr. Meade Bolton for the American Committee on 

Disinfectants : — 

Table XXX. 



Organism. 


Chloride of 
Lime. 


Mercuric 
Chloride. 


Carbolic Acid. 


Typhoid bacillus 

Cholera spirillum .... 
Anthrax spores 

Staphylococcus aureus . . . 
Staphylococcus citreus . . 
Staphylococcus albus . . . 


1 : 2000 
1 : 2000 
1:100 

1:200 

1:50 

1:200 


1:10,000 
1:10,000 
1:1000 


1:100 
1:100 
1:50 
(Uncertain.) 
1:100 
1:100 
1:100 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 389 

Assuming that infectious diseases are caused by micro- 
organisms, and that these are different from the micro-organisms 
of ordinary decay or putrefaction, it can be readily understood 
that the processes of organic decomposition may themselves act 
as disinfectants. It is known, for example, that when a fer- 
menting liquid putrefies, the organisms of fermentation disap- 
pear and give place to the organisms of putrefaction (bacterium 
termo, etc.). So, likewise, the bacilli of anthrax and of tuber- 
culosis are killed by the putrefactive process, if this takes place 
in the absence of free oxygen. Furthermore, the reproduction 
of organisms of a certain kind ceases when certain chemical (?) 
changes take place in their environment. Fermentation in a 
saccharine liquid ceases and the ferment-organisms die when the 
accumulation of the product of the fermentation (alcohol) has 
reached a certain proportion, although there may still be un- 
decomposed sugar present. In like manner it is intelligible that 
the products of micro-organisms may eventually destroy their 
producers, and so place a limit to the morbid process. The 
specific cause of small-pox, yellow fever, cholera, and similar 
infectious diseases is rapidly destroyed when decomposition of 
the corpses of those dead with such diseases sets in. Hence, 
the reason why infectious diseases are not spread from cemeteries. 

From the foregoing it may be gathered that disinfection 
consists chiefly in a struggle against organized disease-germs. 1 
As, however, experiments and observations have shown that the 
life-history of disease-germs varies with the different organisms 
involved, it becomes evident that specific directions concerning 
disinfection can be given only when the life-history of the 
specific organism is known. 

The American Committee on Disinfectants, to w T hose work 
reference has already been made, divides disinfectants into two 
classes : those efficient for the destruction of infectious material 
containing spores, and those which will destroy infectious ma- 
terial only in the absence of spores. The recommendations of 

l Mueller und Falk, in Realencyclopsedie d. ges. Heilk., Bd. IV., p. 62. 



390 TEXT-BOOK OF HYGIENE. 

the committee, covering not only the appropriate disinfectant to 
be used for the destruction of the organisms, but also the con- 
ditions under which the agent should be used, are as follow : — 
The most useful agents for the destruction of spore-containing 
infectious material are : — 

1. Fire. Complete destruction by burning. 

2. Steam under pressure. 105° C. (221° F.) for ten minutes. 

3. Boiling in water for half an hour. 

4. Chlorinated lime. 1 A 4-per-cent. solution. 

5. Mercuric chloride. A solution of 1 to 500. 

For the destruction of infectious material which owes its infecting 
power to the presence of micro-organisms not containing spores, the 
committee recommends : — 

1. Fire. Complete destruction by burning. 

2. Boiling in water for ten minutes. 

3. Dry heat 110° C. (230° F.) for two hours. 

4. Chlorinated lime. 1 A 2-per-cent. solution. 

5. Solution of chlorinated soda. 2 A 10-per-cent. solution. 

6. Mercuric chloride. A solution of 1 to 2000. 

7. Sulphur dioxide. Exposure for twelve hours to an atmosphere 
containing at least 4 volumes per cent, of this gas in presence of 
moisture. 3 

8. Carbolic acid. A 5-per-cent. solution. 

9. Sulphate of copper. A 5-per-cent. solution. 
10. Chloride of zinc. A 10-per-cent. solution. 

The committee would make the following recommendations with 

reference to the practical application of these agents for disinfecting 

purposes : — 

For Excreta. 

(a) In the sick-room : — 

1. Chlorinated lime in solution, 4 per cent. 
In the absence of spores : — 

2. Carbolic acid in solution, 5 per cent. 

3. Sulphate of copper in solution, 5 per cent. 

(b) In privy-vaults : — 

1. Mercuric chloride in solution, 1 to 500. 4 

2. Carbolic acid in solution, 5 per cent. 

1 Should contain at least 25 per cent, of available chlorine. 

2 Should contain at least 3 per cent, of available chlorine. 

8 This will require the combustion of between 1% to 2 kilogrammes of sulphur for every 
28 cubic metres of air-space. The vaporization of liquid sulphur-dioxide can be more accurately 
regulated. 

4 The addition of an equal quantity of potassium permanganate as a deodorant, and to 
give color to the solution, is to be recommended. 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 391 

(c) For the disinfection and deodorization of the surface of masses 
of organic material in privy- vaults etc.: — 
Chlorinated lime in powder. 

For Clothing, Bedding, etc. 

(a) Soiled underclothing, bed-linen, etc.: — 

1. Destruction by fire, if of little value. 

2. Boiling for at least half an hour. 

3. Immersion in a solution of mercuric chloride of the strength 
of 1 to 2000 for four hours. 

4. Immersion in a 2-per-cent. solution of carbolic acid for four 
hours. 

(b) Outer garments of wool or silk, and similar articles, which 
would be injured by immersion in boiling water or in a disinfecting 
solution : — 

1. Exposure in a suitable apparatus to a current of steam for 
ten minutes. 

2. Exposure to dry heat at a temperature of 110° C. (230° F.) 
for two hours. 

(c) Mattresses and blankets soiled by the discharges of the sick : — 

1. Destruction by fire. 

2. Exposure to superheated steam (105° C. = 221° F.) for ten 
minutes. (Mattresses to have the cover removed or freely 
opened.) 

3. Immersion in boiling water for half an hour. 

Furniture and Articles of Wood, Leather, and Porcelain. 

Washing, several times repeated, with solution of carbolic acid, 2 

per cent. 

For the Person. 

The hands and general surface of the body of attendants of the 
sick, and of the convalescents, should be washed with — 

1. Solution of chlorinated soda diluted with nine parts of 
water (1 to 10). 

2. Carbolic acid, 2-per-cent. solution. 

3. Mercuric chloride, 1 to 1000. 

For the Dead. 
Envelop the body in a sheet thoroughly saturated with — 

1. Chlorinated lime in solution, 4 per cent. 

2. Mercuric chloride in solution, 1 to 500. 

3. Carbolic acid in solution, 5 per cent. 



392 TEXT-BOOK OF HYGIENE. 

For the Sick-room and Hospital Wards. 

(a) While occupied, wash all surfaces with — 

1. Mercuric chloride in solution, 1 to 1000. 

2. Carbolic acid in solution, 2 per cent. 
(6) When vacated : — 

Fumigate with sulphur dioxide for twelve hours, burning at least 1^ 
kilogrammes sulphur for every 28 cubic metres of air-space in the room ; 
then wash all surfaces with one of the above-mentioned disinfecting 
solutions, and afterward with soap and hot water ; finally throw open 
doors and windows and ventilate freely. 

For Merchandise and the Mails. 

The disinfection of merchandise and of the mails will only be 

required under exceptional circumstances ; free aeration will usually be 

sufficient. If disinfection seems necessary, fumigation with sulphur 

dioxide will be the only practicable method of accomplishing it without 

injury. 

Rags. 

(a) Rags which have been used for wiping away infectious discharges 
should at once be burned. 

(6) Rags collected for the paper-makers during the prevalence of 
an epidemic should be disinfected, before they are compressed in bales, 

by- 

1. Exposure to superheated steam (105° C.= 221° F.) for ten 

minutes. 

2. Immersion in boiling water for half an hour. 

Ships. 

(a) Infected ships at sea should be washed in every accessible place, 
and especially localities occupied by the sick, with — 

1. Solution of mercuric chloride, 1 to 1000. 

2. Solution of carbolic acid, 2 per cent. 

The bilge should be disinfected by the liberal use of a strong 
solution of mercuric chloride. 

(b) Upon arrival at a quarantine station, an infected ship should at 
once be fumigated with sulphurous-acid gas, using 1J kilogrammes of 
sulphur for every 28 cubic metres of air-space; the cargo should then 
be discharged on lighters ; a liberal supply of the concentrated solution 
of mercuric chloride (1 to 32) should be thrown into the bilge, and at the 
end of twenty-four hours the bilge-water should be pumped out and 
replaced with pure sea-water; this should be repeated. A second fumi- 
gation after the removal of the cargo is recommended. All accessible 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 393 

surfaces should be washed with one of the disinfecting solutions here- 
tofore recommended, and subsequently with soap and hot water. 

For Railway-cars. 
The directions given for the disinfection of dwellings, hospital 
wards, and ships apply as well to infected railway-cars. The treatment 
of excreta with a disinfectant before they are scattered along the tracks 
seems desirable at all times, in view of the fact that the}' may contain 
infectious germs. During the prevalence of an epidemic of cholera this 
is imperative. For this purpose the standard solution of chlorinated 
lime is recommended. 

From the foregoing it would appear that heat, chlorinated 
lime, mercuric chloride, solution of chlorinated soda (Labar- 
raque's solution), carbolic acid, sulphate of copper, zinc chloride, 
and sulphur dioxide (sulphur - fumes) are the most generally- 
available disinfectants. 

The following " general directions " for the practical appli- 
cation of disinfection are given by the committee : — 

Disinfection of Excreta, etc. — The infectious character of the dejec- 
tions of patients suffering from cholera and typhoid fever is well estab- 
lished ; and this is true of mild cases and of the earliest stages of these 
diseases, as well as of severe and fatal cases. It is probable that epidemic 
dysentery, tuberculosis, and perhaps diphtheria, yellow fever, scarlet 
fever, and typhus fever ma} 7 also be transmitted by means of the alvine 
discharges of the sick. It is, therefore, of the first importance that these 
should be disinfected. In cholera, diphtheria, yellow fever, and scarlet 
fever all vomited material should also be looked upon as infectious. 
And in tuberculosis, diphtheria, scarlet fever, and infectious pneumonia 
the sputa of the sick should be disinfected or destroyed by fire. It seems 
advisable, also, to treat the urine of patients sick with an infectious 
disease with one of the disinfecting solutions below recommended. 

Chloride of lime, or bleaching powder, is perhaps entitled to the first 
place for disinfecting excreta, on account of the rapidity of its action. 
The following standard solution is recommended : — 

Dissolve chloride of lime {chlorinated lime, bleaching powder) of the 
best quality 1 in pure water in the proportion of 6 ounces to the gallon 
(45 grammes to the litre). 

Use 1 quart (1 litre) of this solution for the disinfection of each dis- 
charge in cholera, typhoid fever, etc. 2 Mix well, and leave in the vessel 

1 Good chloride of lime should contain at least 25 per cent, of available chlorine. 
Recently nascent chlorine for disinfecting purposes has been obtained on a large scale by the 
electrolysis of sea- water. 

3 For a very copious discharge use a larger quantity. 



394 TEXT-BOOK OF HYGIENE. 

for at least one hour before throwing into privy-well or water-closet. 
The same directions apply for the disinfection of vomited matters. 
Infected sputum should be discharged directly into a cup half full of the 
solution. 1 A 5-per-cent. solution of carbolic acid may be used instead 
of the chloride-of-lime solution, the time of exposure to the action of the 
disinfectant being four hours. 

Disinfection of the Person. — The surface of the body of a sick person 
or of his attendants, when soiled with infectious discharges, should be at 
once cleansed with a suitable disinfecting agent. For this purpose, solu- 
tion of chlorinated soda (liquor sodse chlorinatse — Labarraque's solution) 
diluted with 9 parts of water, or the standard solution of chloride of lime 
diluted with 3 parts of water, may be used. A 2-per-cent. solution of 
carbolic acid is also suitable for this purpose, and under proper medical 
supervision the use of a solution of corrosive sublimate (1 to 1000) is to 
be recommended. 

In diseases like small-pox and scarlet fever, in which the infectious 
agent is given off from the entire surface of the body, occasional ablu- 
tions with the above-mentioned solution of chlorinated soda are recom- 
mended. 

In all infectious diseases the body of the dead should be enveloped 
in a sheet saturated with the standard solution of chlorinated lime, or 
with a 5-per-cent. solution of carbolic acid, or a 1 to 500 solution of cor- 
rosive sublimate. 

Disinfection of Clothing. — Boiling for half an hour will destroy the 
vitality of all known disease-germs, and there is no better way of dis- 
infecting clothing or bedding which can be washed than to put it 
through the ordinary operations of the laundry. No delay should occur, 
however, between the time of removing soiled clothing from the person 
or bed of the sick and its immersion in boiling water, or in one of the 
following solutions until this can be done : — 

Corrosive sublimate, 1 gramme to the litre (1 to 1000), or carbolic 
acid (pure), 8 grammes to the litre. 

The articles to be disinfected must be thoroughly soaked with the 
disinfecting solution and left in it for at least two hours, after which they 
may be wrung out and sent to the wash. 2 

Clothing or bedding which cannot be washed should be disinfected 

•Recently a small spitting-cup made of stiff paper has been introduced especially for the 
use of consumptives. The cup is carried about by the patient or kept within reach. When the 
cup has been in use for a time, and before the sputa can become desiccated, it is thrown into the 
fire and burned. 

- Solutions of corrosive sublimate* should not be placed in metal receptacles, for the salt is 
decomposed and the mercury precipitated by contact with copper, lead, or tin. A wooden tub 
or earthen crock is a suitable receptacle for such solutions. 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 395 

by steam in a property-constructed disinfection chamber. In the absence 
of a suitable steam disinfecting apparatus, infected clothing and bedding- 
should be burned. 

Disinfection of the Sick-room. — In the sick-room no disinfectant can 
take the place of free ventilation and cleanliness. It is an axiom in sani- 
tary science that it is impracticable to disinfect an occupied apartment 
for the reason that disease-germs are not destnryed by the presence in 
the atmosphere of any known disinfectant in respirable quantity. Bad 
odors may be neutralized, but this does not constitute disinfection in the 
sense in which the term is here used. These bad odors are, for the most 
part, an indication of want of cleanliness or of proper ventilation, and it 
is better to turn contaminated air out of the window or up the chimney 
than to attempt to purify it by the use of volatile chemical agents, such 
as carbolic acid, chlorine, etc., which are all more or less offensive to the 
sick, and are useless so far as disinfection — properly so called — is con- 
cerned. 

When an apartment which has been occupied b} T a person sick with 
an infectious disease has been vacated, it should be disinfected. The 
object of disinfection in the sick-room is mainly the destruction of infec- 
tious material attached to surfaces or deposited as dust upon window- 
ledges, in crevices, etc. If the room has been property cleansed and 
ventilated while still occupied b}^ the sick person, and especialty if it 
was stripped of carpets and unnecessar3 r furniture at the outset of his 
attack, the difficulties of disinfection will be greatly reduced. 

All surfaces should be thoroughly washed with the standard solu- 
tion of chloride of lime, diluted with 3 parts of water, or with 1 to 1000 
solution of corrosive sublimate. The walls and ceiling, if plastered, 
should be subsequently treated with a lime-wash. Especial care must 
be taken to wash away all dust from window-ledges and other places 
where it ma}- have settled, and thoroughly to cleanse crevices and out- 
of-the-way places. After this application of the disinfecting solution, 
and an interval of twent} T -four hours or longer for free ventilation, the 
floors and wood-work should be well scrubbed with soap and hot water, 
and this should be followed b}' a second, more prolonged exposure to 
fresh air, admitted through open doors and windows. 

As an additional precaution, fumigation with sulphurous-acid gas is 
to be recommended, especially for rooms which have been occupied by 
patients with small-pox, scarlet fever, diphtheria, typhus fever and j^el- 
low fever. But fumigation with sulphurous-acid gas alone, as commons- 
practiced, cannot be relied upon for disinfection of the sick-room and its 
contents, including bedding, furniture, infected clothing, etc., as is popu- 
larly believed. 



396 TEXT-BOOK OF HYGIENE. 

When fumigation is practiced, it should precede the general washing 
with a disinfecting solution heretofore recommended. To insure any 
results of value, it will be necessary to close the apartment to be disin- 
fected as completely as possible by stopping up all apertures through 
which the gas might escape, and to burn not less than 3 pounds of 
sulphur for each 1000 cubic feet (1^ kilogrammes to 28 cubic metres) of 
air-space in the room. To secure complete combustion of the sulphur, 
it should be placed, in the form of powder or small fragments, into a 
shallow iron pan, which should be set upon a couple of bricks in a tub 
partly filled with water, to guard against fire. The sulphur should be 
thoroughly moistened with alcohol before igniting it. 1 

Disinfection of Privy-vaults, Cess-pools, etc. — When the excreta 
(not previously disinfected) of patients with cholera or typhoid fever 
have been thrown into a privy-vault this is infected, and disinfection 
should be resorted to as soon as the fact is discovered, or whenever there 
is reasonable suspicion that such is the case. It will be advisable to take 
the same precautions with reference to privy-vaults into which the ex- 
creta of yellow fever have been thrown, although we do not definitely 
know that this is infectious material. 

For this purpose the standard solution of chloride of lime may be 
used in quantity proportioned to the amount of material to be disin- 
fected, but where this is considerable it will scarcely be practicable to 
sterilize the whole mass. The liberal and repeated use of this solution, 
or of a 5-per-cent. solution of carbolic acid, will, however, disinfect the 
surface of the mass, and is especially to be recommended during the epi- 
demic prevalence of typhoid fever or of cholera. 

All exposed portions of the vault, and the wood-work above it, 
should be thoroughly washed down with the disinfecting solution. In- 
stead of the disinfecting solutions recommended, chloride of lime in 
powder may be daily scattered over the contents of the privy- vault. 

Disinfection of Ingesta. — It is well established that cholera and 

typhoid fever are very frequently, and perhaps, usually, transmitted 

through the medium of infected water or articles of food, and especially 

milk. Fortunate^, we have a simple means at hand for disinfecting such 

infected fluid. This consists in the application of heat. The boiling 

temperature maintained for half an hour kills all known disease-germs. 

So far as the germs of cholera, yellow fever, and diphtheria are concerned, 

there is good reason to believe that a temperature considerably below 

the boiling-point of water will destroy them. But in order to keep on 

the safe side, it is best not to trust anything short of the boiling-point 

(100° C. = 212° F.) when the object is to disinfect food or drink which is 

1 Liquid anhydrous sulphur-dioxide may he used, and will probahly give hetter results 
than combustion of sulphur. 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 



397 



open to the suspicion of containing the germs of an} 7 infectious disease. 
During the prevalence of an epidemic of cholera it is well to boil all water 
for drinking purposes. After boiling, the water may be filtered, if neces- 
saiy, to remove sediment, and then cooled with 'pure ice if desired. 

The following substances are antiseptics, but in the 
strength given cannot be depended upon as disinfectants : — 



Table 

Thymol, 

Bichloride of mercury, 


XX3 


:i. 






1 : 80,000. 
1 : 40,000. 


Oil of mustard, 








. 1:33,000. 


Acetate of alumina, 








. 1:6310. 


Bromine, 








. 1:5597. 


Picric acid, . 








. 1 : 5000. 


Iodine, 








. 1:4000. 


Sulphuric acid, 








. 1 : 800-1 : 3353. 


Permanganate of potassium, 








. 1:3000. 


Camphor, 








. 1 : 2500. 


Eucalyptol, . 
Chromic acid, 








. 1 : 2500. 
. 1 : 2200. 


Chloride of aluminum, . 








. 1 : 2000. 


Hydrochloric acid, 








. 1:1700. 


Benzoic acid, 








. 1 : 1439. 


Quinine, . 








. 1:1000. 


Boric acid, . 








1 : 200-1 : 800. 


Salic} T lic acid, 
Carbolic acid, 








1 : 200-1 : 800. 
. 1:500. 


Sulphate of copper, 
Nitric acid, . 










1:400. 
1 : 400. 


Biborate of soda, . 










1 : 200. 


Sulphate of iron, . 
Creasote, 










, 1 : 200. 
1 : 200. 


Arsenious acid, 










1 : 100. 


Pyrogallic acid, 
Tr. chloride of iron, 










. 1 : 62. 
1:25. 


Alcohol, 






. 40 


to 9 


5 per cent. 



The agents mentioned in the above list may all be used 
with satisfactory results in surgical and obstetrical practice as 
antiseptics, but it must be borne in mind that the great danger 
in treating wounds comes from carrying infectious particles to 
them in the hands or instruments of the operator. In order to 



398 TEXT-BOOK OF HYGIENE. 

render these aseptic the most thorough measures of disinfection, 
such as heat, strong chemical disinfectants, and physical as well 
as chemical and biological cleanliness are indicated. In a sur- 
gical wound, or in the vagina and uterus of the parturient 
woman, the use of antiseptics is entirely secondary to disinfec- 
tion, under which may primarily be understood rigid cleanliness. 

In public and private sanitation, antiseptics have, as in 
practical surgery, a subordinate importance. 

Deodorizers are sometimes useful in sanitary practice, but 
care must be taken not to look upon deodorization as equiva- 
lent to disinfection. Among the most useful deodorizers are 
chloride of zinc, chloride of lime, permanganate of potassium, 
and a number of the agents mentioned in Table XXXI. 

[The following additional works are recommended for 
study in connection with this chapter : — 

Sternberg and Magnin, The Bacteria, 2d ed. — Fluegge, Fermente 
und Mikroparasiten, in von Pettenkofer und Ziemssen's Handb. d. 
Hygiene, I Th., 2 Abth., 1 Hft. — Wernich, Desinfectionslehre zum prak- 
tischen Gebrauch. — Tallin, Traite des Disinfectants etde la Disinfection. 
— Final Report of the Committee on Disinfectants of the American 
Public Health Association. — Sternberg, Disinfection and Personal 
Prophylaxis Lomb Prize Essay, 1886.] 



QUESTIONS TO CHAPTER XX. 

Antiseptics, Disinfectants, and Deodorants. 

What is an antiseptic ? How may it be used ? Is it necessarily a 
disinfectant ? Why ? Is a disinfectant an antiseptic ? Why ? Why 
must disinfection be thorough to be of any value ? What is necessary 
that there may be disinfection ? How is the term often popularly, but in- 
correctly, used ? 

What is the essential difference between a disinfectant and a de- 
odorant ? What is a germicide ? What is the true test of the value of a 
disinfectant ? Have deodorants as such any real sanitary value ? How 
do disinfectants differ in relation to disease-germs ? How do the latter 
differ in relation to the former ? How may the products of putrefaction, 
fermentation, or decay act as disinfectants ? How may the products of 
the disease-germs themselves act as antiseptics or disinfectants ? 

How may disinfectants be classified? What are most useful agents 
for destroying spore-containing infectious material ? How should these 
be used ? What do we call disinfection by fire or heat ? What agents 
may be used to disinfect infectious matter not containing spores ? Which 
are most efficacious ? What is an essential factor in the successful use 
of all disinfectants ? 

In what diseases may the excreta be infected ? What disinfectants 
may be used for excreta in the sick-room ? In cess-pools ? Why is 
mercuric chloride not so efficacious here ? What is the objection to the 
use of carbolic acid in typhoid fever? Why is chlorinated lime such a 
valuable disinfectant? How much chlorine should it contain? How 
should it be prepared ? What is " milk of lime," and what value has it 
as a disinfectant for excreta ? 

How may soiled underclothing, bed-linen, etc., be disinfected ? How 
long should clothing be boiled in order to thoroughly disinfect it ? How 
may clothing that would be harmed by immersion or chemicals be dis- 
infected ? What will be the effects on clothing of chlorine and sulphur 
gases? How may mattresses, blankets, etc., be disinfected? How long 
should the active process require ? 

(399) 



400 QUESTIONS TO CHAPTER XX. 

"What are some of the best disinfectants for use on the person ? How 
may the danger of infection from a case of scarlet fever, small-pox, etc., 
be lessened ? How should the bodies of those dead of infectious dis- 
eases be cared for ? 

What can be done in the way of disinfection during the occupancy 
of the sick-room ? What are the only disinfectants available ? What 
value will deodorants have here ? What method is to be followed as soon 
as the sick-room is vacated ? Describe in detail. 

How may suspected merchandise and the mails be purified ? What 
treatment should rags, etc., undergo? What is the method prescribed 
for the disinfection of a ship? For railway-cars? (See chapter on 
Quarantine.) 

How may articles of food and drink be made sterile and safe for use ? 

How are antiseptics and disinfectants to be used, and for what pur- 
pose, in surgical and obstetrical practice ? 



CHAPTER XXL 

Vital Statistics. 

(Revised by Seneca Egbert, A.M., M.D.) 

The registration of vital statistics comprises the recording 
of the births, marriages, deaths, and diseases of a city, State, or 
nation. The facts thus secured must be properly classified and 
studied, for in no other way can a knowledge of the health of 
the inhabitants of such communities be obtained, and a real 
test is thus also furnished of the actual efficiency of sanitary 
undertakings. We may, indeed, study disease both by observa- 
tion and experiment, thus learning that some maladies are more 
preventable than others and discovering their causes and means 
of prevention ; and it is also true that for smaller or special 
communities, such as armies, navies, schools, or special classes 
of workmen, the health status may be obtained by direct 
methods ; but for large communities this is clearly impracti- 
cable, and the sanitarian is obliged to depend upon the census 
and the above-mentioned registration. 

The census is the count of its population which every 
civilized country makes at certain intervals, its returns also 
including particulars as to age, sex, race, occupation, etc. 
From the sanitarian's stand-point the age-record is, next to the 
population, the most important return, for the death-rate varies 
most according to age. In this country the census now fur- 
nishes various data for localized " sanitary districts," which may 
be even smaller than city wards, and these data afford the basis 
of comparison for variations in different parts of the same city 
and at different periods. 

The records of births, marriages, deaths, and diseases are 
obtained from the registration bureau, having been furnished 
the latter by duly authorized persons. The duty of registration 
should devolve upon the sanitary administration, such as the 

(401) 



402 TEXT-BOOK OF HYGIENE. 

local or State board of health, this being the most appropriate 
medium for the collection of the information in question, while 
the individual returns should obviously be made to the bureau 
by the attending physician in each case. And, as these returns 
should be as accurate as possible, especially as regards the diag- 
nosis of preventable diseases and the determination of the causes 
of death, both primary and secondary, it is one of the reasons 
why the State should carefully determine the qualifications of 
the physicians whom it allows to practice within its confines.- 

From a sanitary point of view, the most important object of 
a registration of vital statistics is to " give warning of the undue 
increase of disease or death presumed to be due to preventable 
causes, and to indicate the localities in which sanitary effort is 
most desirable and most likely to be of use." 1 

It should be remembered that the following fundamental 
principles that underlie all statistical inquiries must be consid- 
ered in the examination and analysis of any records or reports 
of the kind in question : — 

1. The numerical units with which the inquiry has to do 
must be constant, definite, and precise in character ; if any lack 
these qualities, such should be omitted altogether. Hence the 
care that should be observed in the diagnosis of all cases. 

2. Groups of the numerical units must be so arranged 
that no unit is in more than one group at a time, and so that 
there can be no question as to the group in which each unit 
belongs. This is comparatively simple where the grouping 
regards only the age, sex, race, etc., but the difficulty increases 
with the complexity of facts and requires special talent to 
properly analyze and develop all possible features. 

3. There must be a standard to express the relation of 
each group to the sum of the individual unit. This is usually 
100, 1000, or some multiple of either. 

4. The relation of each group to the total units is not a 

1 J. S. Billings. " Registration of Vital Statistics," American Journal of the Medical Sci- 
ences, vol. lxxxv, p. 37. 



VITAL STATISTICS. 403 

constant one unless all the factors which govern that relation 
are fixed and invariable, — a condition which obviously does 
not obtain in vital statistics. The limit of variation in the 
relation of the component groups to the total, in two or more 
similar series, may, however, be expressed mathematically, and 
the variation itself will be found to diminish as the sum of in- 
dividual units increases. Thus, if, in the formula m + n = q, 
m be the number of units in one group and n the number in 
the other, the limit of variation will be indicated by the expres- 
sion 2\/^; or, again, the relative value of two or more series 
is as the square roots of the number of units in the respective 
series. 

The arithmetical mean is often used in vital statistics, and 
this will always approximate the invariable if the number of 
units is sufficient, -but it must be remembered that the relation 
expressed by the average in one case cannot be predicated posi- 
tively of any other. As Dr. Guy says, " Averages are numerical 
expressions of probabilities ; extreme values are expressions of 
possibilities." 

The graphic representation of statistical results, examples 
of which are given on pages 21 to 25 of this volume, is of 
advantage, since it brings their salient features clearly before 
the attention of the observer. 

The numerical units with which we are concerned in vital 
statistics are persons, either living or dead, and these are di- 
vided into groups according to age, sex, race, etc. Populations 
tend naturally to increase, the natural increment being meas- 
ured by the difference in the number of births and deaths ; but 
the actual increment depends upon how this is modified by the 
relation between immigration and emigration. If these factors 
were all constant, the population would increase in geometrical 
progression ; but as this is not so, it cannot be exactly deter- 
mined for periods other than those in which the census is 
taken. However, in determining the population for years other 
than census years, it is customary to assume that the same rate 



4(U TEXT-BOOK OF HYGIENE. 

of increase continues as prevailed between the last two cen- 
suses, and to calculate the population therefrom by means of 
geometrical progression or logarithms. The number of houses 
in a city will help to determine the approximate population, for 
the average number of persons to the house in any city remains 
about the same from year to year. Such counts, as well as 
police censuses, are, however, almost always too high. In 
small and slowly-growing districts one-tenth of the difference 
in population of the last two censuses may be taken for each 
year since the last census. The population is always counted 
and annual birth- and death- rates calculated for the middle of 
the year in this country. 

REGISTRATION OF BIRTHS. 

The collection of data for an accurate registration of births 
is much more difficult than the record of deaths. Instead of 
requiring physicians and mid wives in attendance at the confine- 
ment to report births, it would be more equitable and probably 
more effectual to compel the parents, under penalty for failure, 
to record the birth of each child at the board of health. The 
items usually included in birth returns are : date and place of 
birth, sex and color of child, names of father and mother, 
parents' nativity and age, and father's occupation. Sometimes 
the residence of the mother, number of children previously 
borne by the same mother, whether the child is legitimate or 
not, and various other details are also added. It is evident that 
for sanitary purposes most of this information is entirely irrele- 
vant. It seems to the author that, for the purpose of the sani- 
tarian and medical statistician, the date and place of birth, sex 
and color of the child, and age, nativity, and occupation of both 
parents are sufficient. 

REGISTRATION OF MARRIAGES. 

The record of marriages is of no interest to the sanitarian. 
If, however, the registration could be made by a competent 



REGISTRATION OF DEATHS. 405 

medical man, and the physical condition of the contracting 
parties noted, valuable deductions might be made in time, espe- 
cially if the parties themselves and their offspring could be kept 
under observation for many years. This, however, is so mani- 
festly impracticable that it barely deserves notice in this place. 

REGISTRATION OF DISEASES. 

As has been seen in Chapter XIX, a large class of diseases 
are communicable from one individual to another, either di- 
rectly, by contact, or mediately, by infection. In large com- 
munities it is therefore important that the sanitary authorities 
should possess information of the presence and prevalence of 
these diseases, in order that measures may be instituted for their 
restriction. It is true that in most cases the registration of 
deaths gives but too mournful evidence of the more fatal of the 
diseases of this class, but destructive epidemics could probably 
be frequently averted if preventive measures could be enforced 
early. Besides, in the case of dengue and epidemic influenza 
the death-rate may be so small that, if the registration of deaths 
were alone depended upon, no evidence whatever might be at- 
tainable of the epidemic prevalence of such diseases. 

The registration of prevailing diseases is, therefore, one of 
the most important duties of the registrar of vital statistics. 
Prompt notice of all cases of infectious, miasmatic, or contagious 
diseases coming under their professional notice should be re- 
quired of all physicians. It is unquestionably just, however, 
that the physicians required to perform this duty should be 
properly compensated by the publie, whose interests they serve. 

REGISTRATION OF DEATHS. 

The data entered upon the record of death should comprise 
the name, age, sex, color, nativity, descent, occupation, and civil 
condition of decedent, with date, place, and cause of death. 
Under the heading " Descent " the birthplace of each parent 
should be given. Occupation should be accurately specified. 



406 TEXT-BOOK OF HYGIENE. 

The place of death should indicate the exact locality (number 
of street) where it occurred. Both proximate and predisposing 
causes of death should be entered, and any complications which 
may have influenced the fatal termination should be noted on 
the record. 

This record should be in the possession of the local health 
authority before a permit for the burial of the deceased is 
granted. If this is not insisted upon, the report will soon be 
omitted and the registration become defective. In fact, any 
system that puts ofT the collecting and recording of the death 
returns till the end of the year will fail to register from 25 to 40 
per cent, of the number. 

DEATH-RATE AND BIRTH-RATE. 

In order to calculate the annual death-rate of a place two 
facts are required to be known : first, the actual or estimated 
population (generally obtained, as indicated, from the census), 
and, second, the number of persons who died in the district 
during the year. The number of deaths is divided by the pop- 
ulation, which gives the death-rate for each individual for the 
year. To find the death-rate per 1000 the rate as found above 
is multiplied by 1000. Thus, the total number of deaths in the 
city of Philadelphia during 1893 was 23,655, and the estimated 
population 1,115,562. The death-rate for the year was 21.20 
per 1000, obtained as follows: — 

23,655 X 1000 01 OA ,, 

— l = 21.20 per M. 

1,115,562 

To calculate the annual death-rate per 1000 of a place 
from the returns for one week, the weekly population is first 
ascertained and then the number of deaths for the week divided 
by the weekly population and the quotient multiplied by 1000. 
The following example will render this clear : — 

The exact number of weeks in a year is 52.17747. The 
total population is divided by this number, giving the weekly 
population. This gives for Philadelphia, assuming the above 



DEATH-RATE AND BIRTH-RATE. 407 

estimate to be correct, a weekly population of 21,381. For the 
week ending June 3, 1893, the deaths in that city numbered 
388. The annual death-rate per 1000, — that is to say, the 
number of deaths in each 1000 of population, if the same rate 
be maintained throughout the year, — is obtained as follows : — 

388X1000 1Q1K Ar 

= 18. lo per M. 

21,381 

The daily death-rate is obtained in a similar manner, the 
divisor for obtaining the daily population being 365.21226. 
and the monthly population is found by multiplying the daily 
population by the number of days in the respective months. 
But it should be remembered that these rates for such short 
periods cannot by any means accurately indicate the actual 
annual rate, and that they are to be used only for comparing 
the rates for similar periods at different seasons, etc. ; otherwise, 
with such large populations and such short periods the proba- 
bilities of error are too great for the results to be of any value. 

The annual zymotic or infectious death-rate, or that for 
anv one disease, is obtained in the same manner as the oeneral 
annual death-rate, and likewise the birth-rate. Or. to find the 
annual death-rate per 1000 of population for this class of dis- 
eases, the following calculation may be made. Thus, out of the 
above 388 deaths, 84 were from infectious diseases : — 

84 X 1000 

91 38 p =* 3.93 per M. per annum. 

Or, if the percentage of deaths from infectious diseases be 
desired, the procedure would be as follows : — 

84 X 100 

— — — — = 21.65 per cent, of the total deaths. 

GOO 

As an exception to the rule, the rate of infant mortality or 
infantile death-rate is indicated by the ratio of deaths of chil- 
dren under one year to the number of births recorded for the 
year, and is found by multiplying the number of infantile deaths 
by 1000 and dividing by the number of births; for example, for 



408 TEXT-BOOK OF HYGIENE. 

the year just quoted the decedents under one year of age num- 
bered 5710; the total number of births for the same year was 
30,737. Hence — 

5710 X 1000 

30T37 = 185.n per 1000 births. 

Nineteen of the 388 deaths for the week ending June 3d 
were of colored persons. The death-rate of these to the total 
population is found in a similar manner to the above ; but if it 
is desired to ascertain the death-rate of the colored population 
alone, the weekly colored population must first be obtained, and 
the rate calculated from this by the above formula. 

There are a number of factors that affect the general death- 
rate, such as the size of the community, habits of life, age- and 
sex- distribution, occupation of the bulk of the inhabitants, etc. 
For the country and small towns the rate should be from 9 to 
16 per 1000, gradually increasing until for the largest cities it 
amounts to from 18 to 21 per 1000. Death-rates reported below 
these figures would indicate that all the deaths had not been 
recorded, or that the population had been overestimated ; rates 
above would be evidence that there were special causes at work 
demanding sanitary investigation and improvement. 

Among the causes that make the mortality among infants 
and children high are parents too young or sickly, hereditary 
taints, unhealthy environments, improper and insufficient food 
and clothing, and, not rarely, infant life-insurance. It is simply 
the manifestation of one of the workings of the law of " the 
survival of the fittest." In localities newly settled, where the 
proportion of adults to children is greater than the normal, the 
death-rate is naturally lower ; though it is conceivable that the 
occupations in which the adults engaged and the vicissitudes 
and unsettled conditions, both sanitary and social, of a new 
settlement might cause or tend to cause a very high mortality. 
Since more males die than females, the sex-distribution will also 
have its influence on the death-rate, especially if there is a 
preponderance of one sex over the other in any locality. 



DEATH-RATE AND BIRTH-RATE. 409 

Many conditions affect the death-rate from the different 
diseases, namely, age, race, sex, occupation, environment, sea- 
sons, temperature, etc. The zymotic death-rate, and especially 
that part of it due to typhoid fever, may be an extremely good 
index of the actual value and benefit of sanitary improvements 
and the enforcement of hygienic laws. Thus, the mortality 
from typhoid fever in England and Wales has been reduced 
more than 50 per cent, since the introduction and enforcement 
of the general sanitary regulations in that kingdom. 

On account of the lack of registration of all cases of dis- 
ease, it is practically impossible to determine the sick-rate of a 
community or population; but it is said that the sickness of a 
community amounts to the disablement of one person for two 
years for every death, and the records of English beneficial 
societies seem to show that each member averages about one 
and one-half weeks' sickness annually. 

The following definitions are introduced because the terms 
are frequently used in discussions of vital statistics, and especially 
of life-insurance. The comparative mortality figure indicates 
that the same number of persons that gave 1000 deaths in the 
whole population would furnish the deaths indicated by the 
figure in the city or locality in question. Thus, if the com- 
parative mortality figure of a place is 925 and the death-rate 
of the country is 20, there are 1000 deaths for every 50,000 
of the whole population and the death-rate of the given place 
is 18.5. For 20 : 1000 : : x : 925 and x = 18.5. 

The average or mean age at death is ascertained by adding 
up the ages of all the decedents and dividing the sum by the 
number of deaths. Unless it is derived from the life-tables of 
an entire generation, it is not a fair index of longevity or of 
sanitary conditions, since it is affected considerably by the age- 
distribution of the population from which it is compiled. 

The expectation of life at any age is the average number 
of years which persons of that age may expect to live. For the 
newborn it is the same as the mean duration of life, and, "as 



410 TEXT-BOOK OF HYGIENE. 

applied to communities, it is the mean life-time of a generation 
of persons traced by the life-table method from birth to death, 
and is the only true test of the health of populations." A life- 
table is computed from the number and ages of the living and 
of those that die, these factors being obtained from the average 
population for each age and sex, and from the total death- 
returns between two or more censuses. It is, as Dr. Farr 
says, "a barometer which indicates the exact measure of the 
duration of life under given circumstances, and is indispensable 
in gauging the influence of sanitary or insanitary conditions." 

It is only when the population does not vary as to age- or 
sex- distribution that the mean duration of life is identical with 
the average age at death. Otherwise, for any person at any age 
it is the same as the expectation of life. The probable duration 
of life is equivalent to the age at which any number of newborn 
children will be reduced one-half, the same conditions persist- 
ing. With a million children as a basis, it is less than forty- 
five years for males and about forty-seven years for females. 

It will be evident, on a little thought, that there must be 
many sources of error in calculations based upon such uncertain 
data as are derived from the registration of births and deaths as 
conducted in most cities in this country. Besides, the subject 
of vital statistics is essentially abstruse, and requires no little 
readiness in mathematics to appreciate its profounder bearings. 
Hence, in the foregoing chapter, no attempt has been made to 
penetrate beyond the immediate practical aspects of the ques- 
tions involved. 

[To those desiring fuller information upon this subject the 

following works are recommended : — 

Curtis, " Vital Statistics," in Buck's Hygiene and Public Health. — 
Billings, " Registration of Vital Statistics," American Journal of Medical 
Sciences, vol. lxxxv. — OldendorrT, " Morbilitsets und Mortalitsets-Statis- 
tik," ne Realencyclopsedie d. ges. Heilk., Bd. ix. — Billings, " Papers on 
Vital Statistics," Sanitary Engineer, vols, viii and ix. — Ibid., Cartwright 
Lectures on Vital and Medical Statistics, 1890. — Wilson, Hand-book of 
Hygiene and Sanitary Science.] 



QUESTIONS TO CHAPTER XXL 

Yital Statistics. 

What is comprised in the registration of vital statistics ? How are 
they to be made of use ? Of what value are the recorded statistics to 
the sanitarian? How else may disease be studied? Why may not the 
same methods of determining the general health be applied to large com- 
munities as to small ones ? 

What is the census ? What returns of interest to the sanitarian does 
it make ? Which of these are the most important ? Why ? What is 
the advantage of furnishing returns for " sanitary districts," and what 
is meant by the latter ? 

What returns are to be obtained from the registration bureau ? Who 
furnishes these returns ? Who should have charge of the registration ? 
Why? Why should physicians make the returns? Why should the 
State take care in the licensing of physicians to practice ? What is the 
most important object of the registration of vital statistics? 

What are the fundamental principles underlying all statistical in- 
quiry ? What units or cases should be omitted ? What renders the 
classification of groups difficult? What is the usual standard of com- 
parison ? When is the relation of component groups to the total con- 
stant? How may the probable limit of variation be determined? What 
tends to make the arithmetical mean approach the invariable ? How ma}- 
the relative value of different series of the same kind of cases be deter- 
mined ? What is the difference between averages and extreme values ? 
Of what value is the graphic method of representing statistical results? 

What are the units of vital statistics ? How may they be divided 
into groups ? What is the natural increment of a population ? How 
does this differ from the actual increment? If the factors were constant, 
how would a population increase ? WI13' ? Why cannot the population 
be determined exactl} T for intercensal periods ? What is the usual 
and most accurate wa} T of determining it ? How else may it be esti- 
mated ? What is the fault of counts made by local authorities or police 
censuses ? At what time of the year is the count always made ? For 
what time are annual death-rates, etc., calculated? 

Why is the collection of data for birth-records difficult ? Who 
should make the return? What items are usually included in the 
returns? Which are the only ones of value to the sanitarian and 
medical statistician ? Why is the record of marriages of no sanitary 
interest ? How might it be made so ? Is this practicable ? 

(411) 



412 QUESTIONS TO CHAPTER XXI. 

What classes of diseases should be reported and recorded? Why? 
What epidemic diseases might escape notice by the statistician if only 
reported in death-returns ? When should the returns of infectious dis- 
eases be made? Should there be any recompense for the returns to the 
physicians ? 

What data should be given by a death-certificate? Which items 
should be accurately specified ? What care should be taken in reporting 
the cause of death ? When should the burial-permit be issued ? 

What factors are required in order to calculate the death-rate of a 
locality ? How is the death-rate for the j^ear obtained ? How may the 
annual death-rate of a place be calculated from the death-returns for one 
week ? What is the weekly and the daily population ? How is the 
monthly population found? What is the objection to rates determined 
from returns for such short periods? Of what value are they? 

What is meant b} T the zymotic or infectious death-rate ? How may 
it be determined ? How is the percentage of deaths due to infectious 
disease determined ? How is the rate of infant mortality determined ? 

What factors affect the general death-rate? What is a fair death- 
rate for small communities ? For large cities ? What do higher rates 
than this usually indicate ? What do lower ones ? What causes make 
the mortality so high among infants and young children ? What may 
make the death-rate of a community lower than the normal? What 
higher ? How may sex-distribution affect the death-rate ? What con- 
ditions or factors affect the mortality from the different diseases ? How 
may the zymotic death-rate be an index of the value of sanitary 
measures ? 

Why is it so difficult to determine the sick-rate of a community ? 
How ma} r the total amount of sickness be approximately estimated ? 

What is meant by the comparative mortality figure? What by the 
average age at death ? Is this necessarily a fair index of longevity ? 
What affects it? What is meant by the expectation of life? Of what 
value is it when applied to communities? What is a life-table, and how 
is it computed? Of what value is it to sanitarians ? When is the mean 
duration of life identical with the average age at death? What is meant 
by the probable duration of life ? Why are calculations of vital statistics 
liable to be unreliable or inaccurate? 



CHAPTER XXII. 

The Examination of Air, Water, and Food. 

(By Seneca Egbert, A.M., M.D., Professor of Hygiene, Medico-Chirurgical 
College, Philadelphia.) 

Occasions often arise wherein physicians or others desire 
information concerning the atmosphere of apartments or con- 
fined spaces, the quality of a drinking-water, or regarding cer- 
tain articles of food. They have neither time, apparatus, nor, 
possibly, the peculiar skill necessary to obtain the accurate 
results of the expert chemist or bacteriologist ; nor do they 
require that the information which they seek should be so 
extremely exact. What they do wish is to know whether the 
object in question is sufficiently pure or safe to use from a 
sanitary point of view, and, if not, wherein it is deficient or 
harmful. . 

In the preparation of this chapter, therefore, such methods 
of procedure will be detailed as will serve to determine, with 
reasonable accuracy and with moderate requirements of time, 
expense, or technical skill, the hygienic condition of the sub- 
stances examined. The apparatus and reagents will also be 
found, for the most part, to be cheap and easily obtainable, and 
they may often be improvised or prepared from material already 
at hand. Moreover, a little thought will show how a number 
of these methods may be developed along the line of greater 
accuracy, should this be desired, and the principles involved 
will indicate how similar examinations may be made of other 
phases of the respective subjects not herein discussed. 

THE EXAMINATION OF AIR. 

As has been indicated in Chapter I, the substances in the 
atmosphere whose proportions or characteristics it may be im- 
portant to determine are : the aqueous vapor ; ozone; suspended 

(413) 



414 TEXT-BOOK OF HYGIENE. 

particles, both organic and inorganic; living micro-organisms; 
volatile organic matters, and the various gases given off as 
products of respiration, combustion, etc., or in the course of 
certain manufacturing processes. 

The proportion of aqueous vapor is to be determined by 
some form of hygrometer, such as Lambrecht's polymeter, or 
from the readings of wet- and dry- bulb thermometers, which 
readings, when applied to Glaisher's tables, furnish a means of 
determining the relative and the absolute humidity, the dew- 
point, the weight of water to a given volume of air, etc. 

The presence of ozone in the atmosphere may be demon- 
strated by exposing to the air strips of white blotting- or filter- 
paper which have been saturated with a solution of potassium 
iodide and starch and dried. The ozone, decomposing the 
potash salt, liberates the iodine and colors the starch blue. 
During the test the paper should not be exposed to dust, rain, 
wind, or the direct rays of the sun. Another test (Houzeau's), 
perhaps even more delicate, is to dampen a strip of faintly-red 
litmus-paper with a solution of the iodide and dry. The action 
of ozone upon this is to liberate the alkaline potash and change 
the litmus to blue. As ammonia is the only other gas likely to 
produce the same coloration, if another strip of the litmus- 
paper, not moistened with the salt, be exposed at the same time, 
whatever difference in shade there may be in the papers is due 
to the ozone. An idea of the quantity of ozone present may 
also be gained by comparing the shade of blue given by either 
test with that produced in similar strips of the starch- or litmus- 
paper, respectively, which have been exposed to certain definite 
amounts of ozone, a series of such papers forming a standard 
of comparison. 

It may be suggested, for still another test, that a definite 
quantity of the air to be examined be drawn through a faintly- 
acid solution of the potassium iodide, phenol phthaleine being 
used as an indicator. As soon as sufficient alkali is liberated 
to neutralize the acidity, the pink color of the phenol phthal- 



THE EXAMINATION OF AIR. 415 

eine will be developed and will deepen as the proportion of 
free alkali increases. Here, also, a control-test to eliminate the 
influence of ammonia should be made by drawing a similar 
quantity of air through the same amount of the solution minus 
the potassium iodide. As before, the difference in color-shading 
will be proportional to the amount of ozone in the air. 

Numerous methods have been suggested for the collection 
of the solid impurities of the atmosphere, varying according to 
the kind or extent of examination to which they are to be sub- 
jected. If they are simply to be studied microscopically, glass 
slides coated with glycerin and exposed to the air, as described 
on page 37, will be sufficiently covered after several hours, or 
they may be collected more rapidly by aspirating large quanti- 
ties of the air against such slides or through tubes coated 
interiorly with glycerin, as by means of Pouchet's aeroscope or 
by the apparatus devised by Dr. S. G. Dixon. This latter is 
especially advantageous where it is desired to collect samples of 
dust in the air of a number of localities within a short time, and 
consists essentially of a double cylinder of metal, within which 
is a rack carrying a number of glycerin- or gelatin- smeared 
cover-glasses. By an ingenious arrangement the air can be 
aspirated by means of a hand-bulb over each of these glasses 
in turn, the dust-particles being deposited on the sticky surface, 
and thus the samples may be taken from as many localities as 
there are cover-glasses. Moreover, the specimens may be 
mounted and examined as they are, may be stained, or, if the 
glasses be coated with gelatin and the whole apparatus be ster- 
ilized before the collection, colonies of the bacteria, etc., in the 
dust may be allowed to develop on the glasses and be studied 
in loco under the microscope. 

Another satisfactory method of collecting suspended par- 
ticles is to draw a considerable volume of air very slowly 
through a small quantity of distilled water contained in one 
or two wash-bottles. The solid particles may then be allowed 
to settle, and subsequently be removed for microscopical ex- 



416 TEXT-BOOK OF HYGIENE. 

animation by means of a pipette, or the whole may be filtered 
and the weight of the dnst in the aspirated air thus obtained. 
It might also be well, in the latter case, to evaporate the filtrate 
to dryness and to determine what proportion of the residue is 
organic matter, and what is its nature and effects when admin- 
istered to animals. Lastly, the air may be slowly drawn through 
a small tube packed with pure sugar, the sugar afterward being 
dissolved in distilled water, whence the solid particles taken 
from the air may be removed by means of a pipette or by 
filtration. 

The physical nature of the particles of dust thus collected 
is to be determined by means of the microscope, it being pre- 
sumed that the examiner is sufficiently familiar with the instru- 
ment to recognize at sight the more common materials that are 
apt to pervade the air of occupied apartments, such as bits of 
cotton, wool, hair, epithelium, etc Charring on ignition will 
indicate that the residue is, at least, partly organic, and the 
odor of burnt feathers that it is nitrogenous and probably of 
animal origin. Suitable chemical tests will also determine the 
presence or absence of suspected substances. Thus, an ex- 
amination of the dust by Marsh's or Reinsch's test may reveal 
the presence of arsenic, and lead to an investigation as to its 
source. 

However, since Cornet and others have demonstrated that 
the micro-organisms in the air are, in general, closely adherent 
to the dust-particles, a bacteriological examination of the latter 
will, except in special cases, be of more importance than a 
physical or chemical one. 

To make a qualitative bacteriological examination it is 
only necessary to coat the glass plates or tubes, already de- 
scribed, with nutrient gelatin instead of glycerin, and to ster- 
ilize them before use. They are then exposed to the air as 
before, covered, and set aside in a place of proper temperature 
to allow the colonics to develop from the various micro-organ- 
isms which have adhered to the sticky surfaces; or Dr. Dixon's 



THE EXAMINATION OF AIR. 417 

apparatus, with gelatin-coated glasses, may be used in the 
manner described. 

A quantitative bacteriological examination is almost as 
readily made by drawing a given quantity of air through a sugar- 
filter, as stated. The tube should not be too large in diameter 
nor in length, should be filled with pure granulated sugar and 
the ends temporarily plugged with cotton, and should, of course, 
be sterilized before making the test. After the air has been 
drawn through it the sugar is carefully emptied into tubes or 
flasks of nutrient gelatin, which have been heated just enough 
to melt the gelatin, but not sufficiently high to kill the bacteria, 
etc., which have been caught in the sugar. The latter rapidly 
dissolves and leaves the micro-organisms free to develop in the 
gelatin, which may be poured out before cooling upon steril- 
ized glass plates or into shallow (Petri) dishes. So-called col- 
onies rapidly develop from the individual bacteria, and the total 
number of these colonies may be assumed to represent the 
number of micro-organisms in the quantity of air aspirated 
through the filter. Moreover, from these colonies pure cultures 
may be made and the nature, etc., of their respective microbes 
determined. To determine the quantity of organic matter in the 
air the most feasible method is to slowly draw a certain volume 
of air through a given quantity of twice-distilled ammonia-free 
water, which retains not only all the volatile and suspended 
organic matters, but also the gases originating therefrom. The 
water is then to be tested by the Wanklyn process for " free " 
and " albuminoid " ammonia, and, if desired, by the Tidy-For- 
chammer process for oxidizable organic matter, though it should 
be noted that in the latter process other gases present in the 
air, such as sulphuretted hydrogen, may help to decolorize the 
permanganate solution, and must therefore be excluded or 
estimated separately. 

However, as these processes are, perhaps, too complex for 
the purpose of this chapter, and as it has been shown by de 
Chaumont and others that the organic matter with which we 

27 



418 TEXT-BOOK OF HYGIENE. 

are usually most concerned — namely, that given off from human 
hodies as a product of respiration and like processes — is pro- 
duced in quantities proportional to the amount of carbon dioxide 
eliminated in the same processes, it generally suffices for our 
purpose to determine the proportion of this gas in the atmos- 
phere, especially as this determination is much more readily 
made than the foregoing one. 

The methods devised by Wolpert and Angus Smith for 
rapidly estimating the percentage of carbon dioxide have 
already been given on pages 33-36, but the following modifica- 
tions of these methods will, it is believed, materially simplify 
them. 

Professor Boom has suggested that, instead of the special 
and somewhat expensive apparatus of Professor Wolpert, a 
mark be made on any test-tube, — say, one inch from the bottom. 
Fix the bulb of any atomizer to a small glass tube — a capillary 
one, if possible — sufficiently long to reach to the bottom of the 
test-tube, and in such a manner that a definite volume of air is 
driven from the atomizer-bulb through the tube at each com- 
pression of the former. In using, fill the test-tube exactly to 
the mark with a clear, saturated solution of lime-water, and 
find how many compressions are needed in the out-door air — 
forcing the air through the lime-water each time and taking 
e#re not to draw any fluid up into the bulb — to make the fluid 
just turbid enough to obscure a pencil-mark or print on white 
paper placed beneath the test-tube and viewed from above. 
Clean the test-tube thoroughly, and repeat the process in the 
apartment of which the air is to be examined. Assuming 
that the out-door air contains the normal proportion of carbon 
dioxide, — viz., 0.04 per cent., — the percentage in the air of the 
room is determined as follows : — 

The number of compressions of the bulb in the out-door 
air : the number of compressions in the room : : x : 0.04 per 
cent., x representing the percentage of carbon dioxide in the 
air of the room. 



THE EXAMINATION OF AIR. 419 

As a modification of the Angus Smith method, the author 
would suggest the following as being, perhaps, more accurate, 
and as certainly not requiring so much apparatus, etc. : — 

To a wide-mouthed bottle, holding about a quart or litre, 
fit a doubly-perforated rubber stopper, one perforation being 
just large enough to receive the tip of a 1 c. c. pipette, the other 
carrying a small test-tube, its mouth opening into the jar and 
close to the inner surface of the stopper. Fill the bottle and 
test-tube with the air of the room by filling them with water 
and emptying ; fit in the stopper, and introduce, by means of 
alec, pipette, a cubic centimetre at a time of a standardized 
alkaline solution, slightly colored with a few drops of a neutral 
alcoholic solution of phenol phthaleine. Close the pipette per- 
foration in the stopper with a bit of glass rod and shake the 
bottle well each time after adding the alkaline solution. Con- 
tinue in this way until the color is no longer discharged by the 
acid carbon dioxide of the air. By having the test-tube fitted 
in the stopper as above and inverting the bottle, the same 
thickness of fluid is observed each time, and there is more 
accuracy than if the bottle is used without the test-tube. In 
either case the fluid should be examined by looking through it 
against a white light or surface. 

Now, since the quantity of the alkaline fluid used indi- 
cates a correspondingly definite amount of carbon dioxide, — 

the number of c. c. of solution used X the volume of C0 2 each c. c. represents X 100 
the capacity of the bottle and test-tube in c. c. — the number of c. c. of solution used 

= the percentage of carbon dioxide in the air examined. 

A suitable alkaline solution may be prepared by dissolving 
exactly 4.766 grammes (73.549 grains) of pure anhydrous 
sodium carbonate in 1 litre (35.238 fluidounces) of distilled 
water. Each cubic centimetre of this solution is equivalent to 
a like volume of carbon dioxide. To 10 cubic centimetres of 
this solution add a few drops of a neutral alcoholic solution of 
phenol phthaleine and dilute with distilled water to 100 c. c. 
Each cubic centimetre of the dilute solution will now be neu- 



420 TEXT-BOOK OF HYGIENE. 

tralized by 0.1 c. c. of carbon dioxide, and, if used as suggested, 

should give close results. The phenol phthaleine is used as an 

indicator, as it loses its color as soon as the alkalinity of the 

soda solution is destroyed by the carbonic acid. Example : If 

1 1 c. c. of the foregoing dilute solution be used, and the capacity 

of the bottle and test-tube is 1153 c. c, then 

11 XO.l X 100 _ 110 _ 
1153 — 11 """ 1U2 — °- 0963 — 

the percentage of carbon dioxide in the air of the apartment. 
The first (stock) solution must be kept in well-filled and 
tightly-stoppered bottles, and the dilute solution made up as 
needed. 

Pettenkofer's method for determining the percentage of 
carbon dioxide in the air, which is usually considered the best, is 
as follows: Into a large, clean bottle or jar, filled with the air 
of the room as on page 419, introduce 50 c. c. of a clear, satu- 
rated solution of lime (calcium hydrate), stopper the bottle, and 
shake it well, so that the air may be well washed by the lime- 
water. This shaking should be repeated at intervals for several 
hours, from eight to ten hours being required for the lime-water 
to absorb all the carbon dioxide in the air in the jar. (How- 
ever, if baryta — barium hydrate — water be used instead of the 
lime-water, the absorption will be completed in an hour.) 

The strength of the lime- (or baryta-) water being un- 
known and variable, it is determined by means of an oxalic-acid 
solution of such strength that 1 c. c. corresponds in acidity to 
0.5 c. c. of carbon dioxide. Such a solution is made by dis- 
solving exactly 2.84 grammes (43.827 grains) of pure crystal- 
lized oxalic acid in 1 litre of freshly-distilled water. This 
acid solution is run into 25 c. c. of the lime-water in a beaker 
from a graduated burette, or pipette, until the alkalinity of the 
lime is just neutralized, the neutral point being indicated either 
by means of a few drops of a neutral phenol-phthaleine solution 
in the beaker or by turmeric paper, the latter being colored 
brown, and the phenol phthaleine retaining its color as long as 



THE EXAMINATION OF AIR. 421 

the solution is alkaline. When the lime is exactly neutralized 
the amount of acid solution used from the burette is noted. 
Then 25 c. c. of the lime-water from the testing-bottle is meas- 
ured into a beaker, and its acidity determined in the same 
manner by means of the oxalic-acid solution. Now, since part 
of the lime in the solution in the testing-bottle has already 
been neutralized by the carbonic acid of the air therein, it will 
require less of the acid solution to neutralize the lime-water 
from the bottle than it did to neutralize the same quantity from 
the stock solution, and the difference will indicate the exact 
amount of carbon dioxide in the air in the testing-bottle. For, 
though each cubic centimetre of acid solution is equivalent to 
only one-half cubic centimetre of carbon dioxide, the loss of 
alkalinity of only half the lime-water in the bottle has been de- 
termined, and the total loss would be expressed by twice the 
difference found. The number of cubic centimetres of carbon 
dioxide in the air in the bottle having been thus determined, 
and the capacity of the bottle found by measuring the quantity 
of water it will hold, the percentage of carbon dioxide in the 
air is readily determined. For example : 25 c. c. of stock lime- 
water requires 30 c. c. acid solution, and 25 c. c. of lime-water 
from testing-bottle requires 27 c. c. acid solution ; therefore, 
30 — 27 = 3 c. c, — the amount of carbonic acid in the bottle, 
which contains, say, 2550 c. c. Then — 

3 X 100 300 _ 012 _ 

2550 — 50 — 2500 ~~ ' ' 

the percentage of carbon dioxide in the room at the current 
temperature and pressure. It should be noted that the accuracy 
of all these tests is somewhat vitiated by other acid gases, if 
present in the air, and due allowance should be made wherever 
they are suspected. 

As has been intimated, baryta-water may be used in place 
of the lime-water, being more rapid in action, but considerably 
more expensive, than the latter. The solution should be made 
of the strength of about 7 grammes of crystallized barium 



422 TEXT-BOOK OF HYGIENE. 

hydrate to the litre of distilled water ; it must not be forgotten, 
also, that it is poisonous when taken internally. A good indi- 
cator, in addition to the phenol "phthaleinc and turmeric, is 
methyl-orange, which is yellow in alkaline and of a reddish tint 
in acid solutions. 

The quantity of ammonia in the atmosphere may be de- 
termined by drawing a certain volume of air through twice- 
distilled water and then " Nesslerizing " the latter, as in the 
Wanklyn process of water analysis. So, also, the presence and 
percentage of other gases, such as nitric, hydrochloric, sulph- 
urous, and sulphuric acid, sulphuretted hydrogen, ammonium 
sulphide, etc., are obtained by drawing the air through distilled 
water and subsequently making the proper chemical tests. For 
instance, the sulphur gas will darken a solution of lead acetate 
and ammonium sulphide will change the blue color of nitro- 
prusside of sodium to violet; consequently, the air may be 
drawn through standard solutions of these reagents and the 
resulting coloration compared with that produced by known 
quantities of the respective gases. 

As indicated on page 36, the presence of carbon monoxide 
is shown by the darkening of a solution of palladium chloride 
or sodio-chloride, but a more delicate test is that of Vogel by 
means of the spectroscope, which will show the presence of as 
little as 0.03 per cent, of the gas. In this test a drop of fresh 
blood is mixed with a little pure water and the mixture well 
shaken with a sample of the air in a jar. Then a few drops of 
ammonium sulphide are added and the fluid examined spectro- 
scopically. If carbon monoxide is present the spectrum of oxy- 
1 Hemoglobin will be seen, it not having been reduced by the 
ammonium sulphide ; but if the carbon monoxide is not 
present, we shall have the spectrum of reduced haemoglobin. 

As even very small quantities of carbon monoxide in the 
air are harmful, it will not often be necessary to make a quan- 
titative test for it; but should this be desired, it can be done by 
passing a given volume of air several times through a solution 



THE EXAMINATION OF WATER. 423 

of subchloride of copper, which absorbs the carbon gas, and 
then determining the loss of volume the air has suffered by 
means of the eudiometer. 

THE EXAMINATION OF WATER. 

A number of tests for impurities in water have already- 
been given on pages 74 to 79, but, as these are mainly qualita- 
tive in character, the author of the present chapter takes the 
liberty of subjoining the following ones, in addition, for the 
benefit of those who may desire a more or less accurate quanti- 
tative knowledge of the various substances in a water that may 
affect its purity from a hygienic stand-point. 

Care should be observed, in collecting samples, that they 
may fairly represent the water to be examined, and not contain 
an excess of impurities. Sufficient of the water should be 
taken for all the tests, — say, two or three quarts, at least, — and 
the receptacles must be chemically clean, preferably of glass, 
and not of tin or metal, and should be thoroughly rinsed several 
times with the water before being finally filled. The stoppers 
must also be clean, and should also be tight enough to prevent 
the escape of gases, as these latter often naturally hold in solu- 
tion substances which would otherwise go to make the water 
turbid, and the loss of which by precipitation might possibly 
change its character. Notes should be made of the time, place, 
surroundings, etc., when each sample is collected, and as much 
information as possible obtained of the conditions which may 
affect the purity of the water. If it is taken from lakes or 
reservoirs, the sample should be from some little distance 
below the surface ; if from hydrants or pumps, the water should 
be allowed to flow awhile, so that the sample may be from the 
main source of supply, and not from that which has been 
standing in the pipe or from storage-tanks. All the tests 
except those for the turbidity, sediment, nitrogen as ammonia 
or as organic matter, and for the oxygen-consuming power, 
should be made with water which has been cleared by sub- 



•42-4 TEXT-BOOK OF HYGIENE. 

sidence or filtration ; those mentioned should be made with the 
sample as taken from the source of supply. 

As indicated in Chapter II, the tests for color, turbidity, 
etc., are made by comparing the sample with an equal volume 
of distilled water, using tall, glass jars of the same calibre, and 
looking down through equal depths upon a white surface. Or 
the turbidity may be indicated by noting the depth which is 
required to obscure print from type of a certain size or font. 

The smell may be detected by heating the water to from 
40° to 60° C. (104° to 140° F.) in a glass-stoppered bottle. 
Sometimes the higher temperature is needed to liberate odorous 
gases that would otherwise be undetected, and, again, there is 
often no smell at all from a very bad water or from one from an 
obnoxious source. The test, therefore, may or may not indicate 
sewage or faecal contamination. 

The impurities that give any perceptible taste to water, 
except when in large amounts, are very few in number, and 
many waters dangerously polluted have a good and pleasing 
taste. Of the metals, iron is the only one which is perceptible 
to the taste in small quantities ; but one-fourth of a grain of 
this base to the gallon may thus indicate its presence. Caution 
should, of course, be observed in tasting waters suspected of 
containing infectious or poisonous matters. 

The proportion of air or gas a water contains is indicated, 
in a measure, by its lustre and by the presence of bubbles on the 
sides and bottom of the vessel, though the number of the latter 
is also affected by the temperature. 

Test for Chlorine. — Solutions required: 1. Standard 
silver-nitrate solution. To 1 litre of pure distilled water add 
4.788 grammes of pure silver nitrate (AgN0 3 ). One cubic 
centimetre of this solution is equivalent to 1 milligramme of 
chlorine. 2. Potassium-chromate solution. A 10-per-cent. 
solution of potassium chromate (K 2 Cr0 4 ) in distilled water 
free from chlorine. 

Process: To 100 c. c. of the water to be tested add a few 



THE EXAMINATION OF WATER. 425 

drops of the potassium-chromate solution, and then run in the 
silver-nitrate solution from a graduated burette, adding it drop 
by drop and stirring the water continually with a glass rod. 
Continue until a faint but permanent orange-red tint has been 
produced, showing that all the chlorine has combined with the 
silver, the persisting reddish tint being due to silver chromate. 
The number of cubic centimetres of silver-nitrate solution used 
indicate the number of milligrammes of chlorine in 100 c. c. of 
the water, or the parts per 100,000; this multiplied by 10 gives 
the number of milligrammes of chlorine in 1 litre, or parts per 
million. If the water contain but little chlorine, the test will 
be more accurate if 250 c. c. of the water be first evaporated 
over a water-bath to about 50 c. c. before proceeding as 
above: four times the result will then give the number of milli- 
grammes of chlorine in 1 litre. Should it be desired to express 
the proportion in terms of sodium chloride, multiply the result, 
obtained as above, by 1.648; or make up the silver-nitrate solu- 
tion by adding 2.905 grammes to the litre, each cubic centimetre 
of this solution being then equal to 1 milligramme of sodium 
chloride. 

Test for Nitrates. — Solutions required : 1. Phenol-sul phonic 
acid. To 37 c. c. of strong sulphuric acid add 6 grammes of 
pure carbolic acid and 3 c. c. of distilled water. 2. Standard 
potassium-nitrate solution. Add 0.722 gramme of fused potas- 
sium nitrate (KN0 3 ) to 1 litre of distilled water. Each cubic 
centimetre of this contains ^ milligramme of nitrogen. The 
water used in making these solutions must be free from nitrates. 

Process : Evaporate 10 c. c. of the water to be tested (or 
25 c. c. if it is presumably low in nitrates) just to dryness. 
This is best done over a water-bath. Add 1 c. c. of phenol- 
sulphonic acid, stir with a glass rod, add 1 c. c. of distilled 
water and 3 drops of strong sulphuric acid ; warm the dish, 
add about 25 c. c. of distilled water, then ammonia to excess, 
and dilute with distilled water to exactly 100 c. c. Treat 1 c. c. 
of the standard potassium-nitrate solution in exactly the same 



426 TEXT-BOOK OF HYGIENE. 

manner and compare the tints produced. Dilute the darker of 
the two with distilled water until the tints match exactly, and 
calculate the amount of nitrogen present as nitrates in the 
water being examined from the amount of dilution necessary. 
Example : The tint from the 1 c. c. of standard potassium- 
nitrate solution is the darker and needs an addition of 
25 c. c. more water before it matches the other. Therefore, 
125 : 100 : : 0.1 : x = 0.08, — the number of milligrammes of 
nitrogen existing as nitrates in the 10 c. c. of water tested. The 
test depends upon the conversion of the phenol-sulphonic acid 
into picric acid by the nitrates and the subsequent formation of 
ammonium picrate, which gives a yellow tint to the water. 
The amount of picric acid and picrate formed is exactly propor- 
tional to the quantity of nitrates present. 

Test for Nitrites. — Solutions required: 1. Sulphanilic acid. 
Dissolve 0.5 gramme of sulphanilic acid in 150 c. c. of dilute 
acetic acid (sp. gr. 104). 2. Naphthylamine acetate. Boil 
0.1 gramme of solid naphthylamine in 20 c. c. of distilled water, 
filter through a plug of washed absorbent cotton and mix the 
filtrate with 180 c. c. of dilute acetic acid. 3. Standard sodium- 
nitrite solution. Dissolve 0.275 gramme of pure silver nitrite 
in pure w 7 ater, add a dilute solution of pure sodium chloride till 
precipitate ceases to form and dilute to 250 c. c. with pure water. 
For use, dilute 10 c. c. of this solution to 100 c. c, each cubic 
centimetre of the latter dilute solution containing 0.01 milli- 
gramme of nitrogen. Keep the stronger solution in the dark 
when not in use, and make up the dilute solution anew each 
time. All water used in these solutions must be free from 
nitrites ; likewise all water used for dilution in the test. 

Process : Measure 25 c. c. of the water to be examined into 
a Nessler tube or large test-tube, add 2 c. c. each of the sulphan- 
ilic acid and naphthylamine-acetate solutions, using a separate 
pipette for each. In a similar tube dilute 1 c. c. of the standard 
sodium-nitrite solution (dilute) to 25 c. c. with nitrite-free dis- 
tilled water, and add the same quantity of the above reagents to 



THE EXAMINATION OF WATER. 427 

it. Compare the colors at the end of five minutes, and esti- 
mate the amount of nitrites by diluting the darker solution till 
it matches the lighter, just as was done in testing for nitrates. 
The foregoing test is a very delicate one, and gives the quantity 
of nitrogen present as nitrites, which should not be over a trace. 

Test for Free and Albuminoid Ammonia. Wanklyn's 
Method. — Solutions required : 1. Standard ammonium-chloride 
solution. Dissolve 0.382 gramme pure dry ammonium chloride 
(NH 4 C1) in 100 c. c. ammonia-free water. Each cubic centi- 
metre of the dilute solution contains 0.01 milligramme of 
nitrogen. 2. Alkaline potassium-permanganate solution. Dis- 
solve 200 grammes of potassium hydrate (KHO) in sticks, and 
8 grammes of potassium permanganate in 1 litre of distilled 
water. Evaporate to about 750 c. c. to drive off any ammonia 
present, and, make up to 1 litre again with ammonia-free 
water. To make ammonia-free water, add about 1 grain sodium 
carbonate to the litre of distilled water, and boil till about 
one-fourth is evaporated. 3. Nessler's reagent. Dissolve 35 
grammes potassium iodide (KI) in 100 c. c. of distilled water, 
and 17 grammes mercuric chloride (HgCl 2 ) in 300 c. c. of 
water ; add the mercuric-chloride solution to the potassium 
iodide until a permanent precipitate is formed. Then dilute 
with a 20-per-cent. solution of sodium hydrate (NaHO) to 1000 
c. c. ; add mercuric-chloride solution till a permanent precipitate 
again forms, and allow to stand until clear. This reagent gives 
a brown or yellowish-brown coloration if ammonia be present 
in water, and improves on keeping. 

Process : Place 500 c. c. of the water to be examined in a 
retort, connect with a condenser, and boil gently so that the 
water may distil over slowly. The retort and condenser should 
have been thoroughly rinsed with ammonia-free water. Collect 
the distillate, 50 c. c. at a time, in Nessler tubes, add 2 c. c. of 
Nessler's reagent to each 50 c. c. and determine the amount of 
ammonia or nitrogen in each, as follows : Place in another 
Nessler tube 50 c. c. ammonia-free water and 2 c. c. Nessler's 



428 TEXT-BOOK OF HYGIENE. 

reagent ; run in from a burette the standard ammonium-chloride 
solution until the color exactly matches that of the first 50 c. c. 
of the distillate. Eepeat the process with each 50 c. c. of dis- 
tillate until the test shows that no more ammonia is coming 
over from the retort. The total amount of ammonium-chloride 
solution used indicates the total amount of nitrogen of the free 
ammonia. Usually all the free ammonia will come over in the 
first 150 c. c. or 200 c. c. of distillate. Compare the colors by 
looking down through the tube upon a white surface. If the 
first 50 c. c. give a precipitate with the Nessler reagent, it must 
be diluted and the amount of nitrogen estimated from the 
diluted distillate. The free ammonia being all determined, 
allow the retort to cool and add to the water remaining in it 50 
c. c. of the alkaline-permanganate solution. This converts a 
certain proportion of the nitrogenous organic matter into am- 
monia. Distil as before, estimating the amount of nitrogen in 
each 50 c. c. of the distillate, until no more ammonia comes 
over. The amount of ammonium-chloride solution thus used 
will indicate the nitrogen of albuminoid ammonia ; and the 
total amount of ammonium-chloride solution used in the whole 
process gives the nitrogen of the free and albuminoid ammonia 
in the 500 c. c. of water. 

Tests for Hardness. — Solutions required : 1. Soap solution. 
Dissolve about 10 grammes of Castile or soft soap in 1 litre of 
weak (35 per cent.) alcohol. 2. Standard lime solution. Dis- 
solve 1.11 grammes pure calcium chloride in 1 litre of distilled 
water. One c. c. of this solution is equivalent to 1 m. g. of 
calcium carbonate (CaC0 3 ). Process : First, find how much of 
the soap solution is needed to make a lather with 100 c. c. of 
distilled water, as follows : Place the water in a flask holding 
about 250 c. c. and run in the soap solution from a burette, a 
few drops at a time, corking and shaking the flask well after 
each addition. The lather should have a depth of about one- 
fourth of an inch, and should be permanent for at least five 
minutes. Then standardize the soap solution by diluting 5 c. c. 



THE EXAMINATION OF WATER. 429 

of the standard lime solution to 100 c. c. with distilled water 
and rinding how many cubic centimetres of the soap solution 
are necessary to make a permanent lather with it. This 
quantity, less the number of cubic centimetres needed to make 
a lather with the 100 c. c. of distilled water, represents the 
amount of soap solution that will neutralize 5 m. g. of cal- 
cium carbonate or its equivalent. Lastly, determine in the 
same way the number of cubic centimetres of soap solution 
necessary to make a permanent lather with 100 c. c. of the 
water to be examined; subtract the quantity necessary for 100 
c. c. distilled water and estimate the amount of calcium carbon- 
ate or its equivalents present, as follows : For example, it takes 
2 c. c. of soap solution to make a lather with the distilled water 
and 12 c. c. with the diluted lime solution. Then, 12 — 2 = 
10 c. c. zz 5 m. g. calcium carbonate, and each cubic centimetre 
of the soap solution zz 0.5 c. c. of the standard lime solution, 
or 0.5 m. g. calcium carbonate. Consequently, if 100 c. c. of 
the water examined require 17 c. c. of soap solution, it must 
contain (17 — 2) X 0.5 zz 7.5 m. g. calcium carbonate or its 
equivalent, and 1 litre of the water contains 75 m. g. calcium 
carbonate. 

Tests for Lead, Copper, and Iron. — To 50 or 100 c. c. of 
the water in a white porcelain dish, or in a tall glass jar, over 
white paper, add a few drops of ammonium sulphide, — (NH 4 ) 2 S. 
A dark coloration or precipitate indicates the presence of either 
lead, copper, or iron, due to the formation of the respective 
sulphide. Then add a few drops of hydrochloric acid (HC1). 
If the color disappear, iron only is present ; if it persist, lead 
or copper is present. In the latter case, add a few drops of 
acetic acid and about 1 c. c. of a strong solution of pure potas- 
sium cyanide. If the color disappear, it is due to copper; if it 
remain, lead is present. If lead only is present in the water, 
the above test will detect ^ grain per gallon. The above test 
may be corroborated as follows : Partly fill two test-tubes with 
the original water ; to one add a little potassium-chromate solu- 



430 TEXT-BOOK OF HYGIENE. 

tion ; an opacity and the deepening of the color to a canary 
yellow indicates lead. To the second add a drop of dilute 
hydrochloric acid and a few drops of potassium-ferrocyanide 
solution; a blue color indicates iron, either ferrous or ferric; a 
bronze or a mahogany-red color indicates copper. Quantitative 
tests for the above metals may be made by making standard 
solutions of the respective elements, treating a measured quan- 
tity of the original water with the proper reagent, as indicated, 
and comparing the color produced with that given by a definite 
quantity of the respective standard solution. 

Test for Phosphates. — Solution required, ammonium molyb- 
date : Dissolve 10 grammes of molybdic anhydride in 41.7 c. c. 
of ammonia (NH 4 HO), — sp. gr. 0.96, — and pour slowly into 125 
c. c. of nitric acid (HN0 3 ), — sp. gr. 1.20 ; allow to stand in a 
warm place for several days till clear. Process : Slightly acidify 
500 c. c. of the water with nitric acid, evaporate to about 50 c. c, 
add a few drops of ferric chloride (Fe 2 Cl 6 ) and ammonia in 
slight excess. Filter, dissolve the precipitate in the smallest 
possible quantity of nitric acid, and evaporate to 5 c. c. Heat 
nearly to boiling ; add 2 c. c. of ammonium-molybdate solu- 
tion ; keep solution warm for one-half hour. If there is an 
appreciable quantity of precipitate, collect it on a small, weighed 
filter-paper, wash with distilled water, dry at 100° P., and 
weigh. The Aveight of the precipitate multiplied by 0.05 gives 
the amount of phosphates as P0 4 in the 500 c. c. of water. 

In the bacteriological examination of water, 1 c. c, or a 
definite fractional part thereof, of the water is to be added to a 
little sterilized nutrient gelatin, heated just enough to liquefy it, 
the whole shaken to thoroughly mix it, and then cooled in an 
even film on the interior of the test-tube (Esmarch's roll-cult- 
ure) or poured out upon sterilized glass plates or into Petri 
dishes. Or, as Prof. LefTmann suggests, flat, rectangular bottles, 
of 8 or 10 ounces' capacity, may be used instead of test-tubes. 
Sufficient nutrient gelatin is placed in each to cover one of the 
flat sides with a thin film, and the bottle stoppered and steril- 



THE EXAMINATION OF FOOD. 431 

ized. Then, when needed, the gelatin is gently melted, the 
measured quantity of water introduced and mixed with the 
gelatin, and the bottle placed on its side until the gelatin cools. 
Within a short time colonies develop from the micro-organisms 
thus fixed in the gelatin, and from these colonies pure cultures 
may be made of the respective species, and further experiments 
and study carried on. 

It must always be remembered that, in collecting samples 
of water for bacteriological examination, great care must be ob- 
served to avoid accidental contamination of the culture-media, 
etc., by extraneous organisms. Where possible, the inoculations 
should be made at the place where the samples of water are col- 
lected, the water being taken up by means of sterilized pipettes 
and measured at once into the sterilized gelatin tubes or bottles. 
If this cannot be done, the water should be collected in well- 
sterilized, glass-stoppered bottles. These should be washed 
externally, submerged, unstoppered, filled and restoppered, — all 
below the surface, — and then transferred to the laboratory and 
the inoculations made as soon as possible, packing them in ice 
if the distance be great or there is any cause for delay, in order 
to prevent the too rapid multiplication of certain of the organ- 
isms and the disappearance of others. 

THE EXAMINATION OF FOOD. 

It would be manifestly inadvisable to attempt to detail, 
within the limits of this chapter, the methods for the determina- 
tion of the purity and healthfulness of the many articles of food 
that make up the daily dietaries of the people at large ; but 
since occasions are constantly arising when it is desirable to 
know something of the condition of certain food-stuffs which are 
used by practically every one, and which are especially liable 
to sophistication or adulteration, the following notes are, there- 
fore, added as being within the scope of the chapter : — 

Milk. — Good milk should be ivory-white in color, opaque, 
of neutral or slightly-alkaline reaction, and should have no 



432 TEXT-BOOK OF HYGIENE. 

sediment nor any unusual taste or odor. The specific gravity 
should be 1029 or above; the proportion of cream, from 10 to 
40 per cent, by volume ; the fats, 3 per cent, or more, and the 
total solids 12.5 per cent, or more. 

The color is enriched by a high percentage of cream, but 
too rich a color or one with a reddish or yellowish tint may in- 
dicate the addition of annatto. A poor color indicates that the 
milk is deficient in fat, and may be due to skimming or water- 
ing, or both, but a peculiar blue color is sometimes produced by 
the growth of a certain fungus in the milk. The lessening of 
fat also tends to make the milk translucent and less opaque. 

An acid reaction, unless very slight, indicates " souring " 
of the milk or the addition of some preservative, such as saly- 
cylic or boric acid ; while a strongly-alkaline reaction points to 
the addition of some substance like chalk, sodium carbonate, 
etc., to increase the specific gravity. Such addition is verified 
by a high percentage of total solids and by the effervescence of 
the latter upon the addition of a drop or two of hydrochloric 
acid. 

The specific gravity is determined by means of the lactom- 
eter, in using which corrections must be made for the tempera- 
ture if the latter varies much from 60° F., the standard. The 
specific gravity is slightly raised by skimming the milk, since 
the cream is lighter than the whole milk, and, theoretically, a 
very high percentage of cream tends to lower the specific 
gravity ; but, in reality, a milk rich in cream is also rich in 
other solids that keep the specific gravity high or, at least, 
normal. 

The percentage of cream is determined by the creamome- 
ter (see page 101), which should be covered and in which the 
milk should stand for eight or ten hours. 

The principal sophistications of milk are by watering, skim- 
ming, the addition of solids to increase the specific gravity or to 
act as preservatives or to mask " souring," and the addition of 
annatto and the like to enrich the color. Watering is indicated 



THE EXAMINATION OF FOOD. 433 

by a low specific gravity and by a low percentage of cream and 
of total solids. Skimming is indicated by a low percentage of 
cream and poor color, though the latter may be disguised by 
the addition of annatto, etc. The specific gravity will be very 
slightly raised by the skimming, but if the milk has been both 
skimmed and watered the density will be lowered. 

To Determine the Percentage of Total Solids. — Weigh a 
small evaporating-dish, preferably platinum. Add 5 or 10 c. c. 
of milk, and weigh the dish and milk to get the weight of 
milk. Evaporate to dryness over a water-bath, completing the 
drying in a water-oven until there is no further loss of weight. 
Weigh the dish and contents (total solids) ; subtract the weight 
of dish and divide by the weight of milk. The result is the 
percentage of total solids. 

To Determine the Percentage of Ash. — Ignite the total 
solids over the naked flame until all black specks have disap- 
peared. Cool and weigh. Divide the weight of ash by weight 
of milk. The result is the percentage of ash. 

To Determine the Percentage of ,Fats. — Proceed as above 
with 10 c. c. of milk and evaporate till the residue is a tena- 
cious pulp. Extinguish the flame, fill the dish half- full of 
ether, and stir and pound the residue thoroughly with a glass 
rod ; filter through a small filter-paper, reserving the filtrate ; 
add more ether to the residue, stir as before and filter, repeating 
the process three times, or till the residue is perfectly white. 
Wash filter-paper well with ether, and evaporate all the ether 
to dryness. Weigh "the residue (the fat) and divide by the 
weight of milk. Result : percentage of fats. 

Test for Annatto. — A percentage of cream considerably 
lower than the color of milk would indicate justifies the sus- 
picion that some coloring matter has been used. This is gen- 
erally annatto. Coagulate one ounce of milk with a few drops 
of acetic acid, and heat ; strain and press out excess of liquid 
from curd. Triturate the curd in a mortar or dish with ether. 
Decant the ether and add to it 10 c. c. of a 1-per-cent. solution 

28 



434 TEXT-BOOK OF HYGIENE. 

of caustic soda. Shake and allow to separate ; pour off the 
upper layer into a porcelain dish. Put in two small discs or 
strips of filter-paper. Evaporate gently ; annatto will dye the 
discs an orange or buff color. Moisten one disc with dilute 
sodium carbonate to fix the color. Touch the other disc with a 
drop of stannous chloride ; annatto will give a rich pink color. 
This test is sensitive to 1 part of annatto in 1000 of milk, and 
with milk in any condition. 

Test for Boric Acid. — In igniting the total solids, boric acid, 
or boron, gives a greenish tinge to flame. Place in a porcelain 
dish one drop of milk, two drops of strong hydrochloric acid, 
and two of a saturated tincture of tumeric. Dry on a water- 
bath, remove as soon as dry, cool and add one drop of ammo- 
nia on a glass rod. A slaty-blue color, changing to green, is 
given if borax is present. This test will show ioV o" g rain of 
borax. Less will give the green color, but not the blue. 

Butter. — Good butter should have a good taste, odor, and 
color ; it should not be rancid, and should not contain too 
much water or salt, nor should it have any added coloring 
matter. The average composition should be about as follows : 
Fat, 82 per cent. ; casein, 2 per cent, (not over 3 per cent.); 
ash or salts, 2 per cent. ; water, 13 per cent. ; milk-sugar, 1 
per cent. Butter-fat is a compound of a glycerin with certain 
fatty acids, some of them volatile and soluble in hot water, 
others non- volatile and insoluble in hot water. 

Oleo-margarine consists of ordinary animal (or vegetable) 
fats melted, strained, cooled with ice, worked up with milk, col- 
ored, and salted. These fats are usually beef or mutton, lard 
or cotton-seed, palm- or cocoa-nut- oil. If care and cleanliness 
are observed in the manufacture, oleomargarine is not harmful 
or innutritious, but it should not be sold as butter. 

Fraud is to be detected by observing the difference in 
composition and properties of the fats. The following table, 
from Kenwood's " Hygienic Laboratory," will show the char- 
acteristic difference in the fats : — 



THE EXAMINATION OF FOOD. 



435 



Butter- Fat. 

1. The specific gravity is very rarely be- 
low 910, never below 909.8. 

2. The soluble, volatile fatty acids aver- 
age between 6 and 7 per cent., never below 
4.5 per cent. 

3. The insoluble fatty acids form about 
88 per cent, of the total weight of butter- 
fat. 

4. The melting-point of the fat varies 
from 86° to 94° F. ; is usually from 88° 
to 90° F. 

5. Is readily and completely soluble in 
ether. 

6. Under the microscope pure butter 
consists of a collection of small oil-glob- 
ules with an occasional large one. No 
crystals, except when the fat has been 
melted. 



Beef-Fat, etc. 
Is never above 904.5. 

Rarely more than y 2 per cent. ; never 
above % per cent. 

Generally about 95 per cent. 



Rarely, if ever, above 82° F. 



Less so, and leaves a residue. 

The contours of the small oil-globules 
are less distinct, and the larger ones are 
more numerous and irregular in size. 
Crystals of the non-volatile acids are often 
seen. 



To Determine the Specific Gravity. — Melt a quantity of the 
butter in a beaker on a water-bath at about 150° F. After a 
time, when the fat is perfectly clear and transparent, carefully de- 
cant from the lower stratum of water, curd and salt on to a fine 
filter ; collect the filtrate and pour into a specific-gravity bottle, 
which has been previously weighed, both when empty and when 
filled with distilled water at 100° F. See that the bottle is 
exactly full of the fat ; wipe clean and weigh when the tempera- 
ture is as near 100° F. as possible, because solidification soon 
begins below this temperature. Subtract the weight of the 
bottle, divide by the weight of the water, and multiply by 1000. 
The result is the specific gravity. 

To Find the Melting- Point — Pour a little melted fat into 
a small test-tube (2" x I"). Partly fill two beakers of unequal 
size with cold water ; place the test-tube in the smaller (taking 
care to allow no water to mix with the fat), and the smaller in 
the larger, and gently heat the outer beaker. Suspend a ther- 
mometer in the smaller, near the test-tube, and note the temper- 
ature when the fat begins to melt. This is the melting-point. 

To Determine the Percentage of Insoluble (Non- Volatile) 
Fatty Acids, — To 5 grammes of butter-fat add 50 c. c, of alcohol 



436 TEXT-BOOK OF HYGIENE. 

containing 2 grammes of caustic potash (KHO) and boil gently 
for fifteen or twenty minutes to saponify the fat. Dissolve the 
soaps thus formed in 150 to 200 c. c. of water and decompose 
with about 25 c. c. of dilute hydrochloric acid. The separated 
fatty acids are collected upon a weighed filter-paper, washed 
with 2 litres of boiling water, dried at 95° to 98° C, and then 
weighed. The weight of these insoluble fatty acids should not 
be over 90 per cent, of the weight of the butter-fat. 

Flour and Bread. — Wheat-flour should be almost but not 
perfectly white, also smooth and free from grit ; it should have 
no moldy or unpleasant odor, and, unless made by the new 
process, should be cohesive when lightly compressed in the 
hand. There should be no signs of parasites or fungi under 
the microscope. The proportion of gluten should be more than 
8 per cent. ; of water, less than 18 per cent., and of ash, less 
than 2 per cent. 

To Determine the Percentage of Water and Ash. — In a 
weighed platinum (or porcelain) dish place about 50 grammes 
of flour, weigh and dry over a water-bath for an hour or so ; 
then complete the evaporation in a water-oven until there is no 
further loss of weight ; weigh, subtract this weight less the 
weight of the dish from the original weight of the flour ; divide 
the remainder, the weight of the water, by the original weight 
of the flour. The result is the percentage of water. Then 
ignite the dried flour in the dish and incinerate till there are no 
longer any black particles and only the ash remains ; cool, 
weigh, and divide by the original weight of the flour. The 
result is the percentage of ash. 

To Determine the Percentage of Gluten. — By means of a 
glass rod, mix a weighed quantity of flour with a little distilled 
water into a stiff dough ; then repeatedly wash away the starch 
and soluble constituents, kneading the dough with the rod or 
fingers and continuing until the wash-water comes away clear; 
the gluten and a small amount of fat and salts remain. Spread 
out on a weighed dish or crucible-lid, dry in a water-oven, and 



THE EXAMINATION OF FOOD. 437 

weigh ; divide by the original weight of the flour. The result 
is the approximate percentage of gluten. The gluten should 
pull out into long threads, otherwise it is poor. 

An excess of water impairs the keeping-quality and lessens 
the amount of nutriment in the flour. An excess of ash indi- 
cates the addition of mineral substances. A deficiency of gluten 
indicates that the flour is not pure wheat-flour. Parasites 
and fungi especially affect or live in old or damp and inferior 
flour. 

To Test for Mineral Substances. — Shake a little flour in a 
test-tube with some chloroform, and allow it to stand for a few 
moments. The flour floats and any mineral matter sinks to the 
bottom, when it can be removed with a pipette and examined 
under a microscope. 

Wheat-bread should be fairly dry, light, and spongy ; clean 
and nearly white ; of pleasant taste ; not sodden, acid, or 
musty ; no parasites or moldiness. It should contain no flour 
other than wheat; but little, if any, alum ; no copper sulphate ; 
and should not yield over 3 per cent, of ash. 

Test for Alum. — Add 5 c. c. of a 5-per-cent. tincture of 
logwood and 5 c. c. of a 1 5-per-cent. solution of ammonium 
carbonate to 25 c. c. of water ; soak a crumb of the bread in 
this for a few minutes ; drain and gently dry. Alum is indi- 
cated by a violet or lavender color, its absence by a dirty-brown 
color on drying. 

Test for Copper Sulphate. — Draw a glass rod dipped in a 
solution of potassium ferrocyanide across a cut slice of the 
bread ; copper is indicated by a streak of brownish-red color. 

Test for Ergot in Flour or Bread. — Add liquor potassse ; 
a distinct, herring-like odor (due to propylamine) is appreciable 
if ergot be present. 

An excess of water, an unnatural whiteness, and a low 
percentage of ash in bread indicate the addition of rice. Pota- 
toes give an increased percentage of water and an alkaline 
ash. 



438 TEXT-BOOK OF HYGIENE. 

[The following works are recommended to those desiring 
fuller details of the foregoing methods, or for the further ex- 
amination of these subjects : — 

Kenwood's Hygienic Laboratory. — Examination of Water for San- 
itaiy and Technical Purposes, by Leff'mann and Beam. — Sanitary Exam- 
inations of Air, Water, and Food, by Fox. — Parkes's Practical Hygiene. 
— Practical Hygiene, by Coplin and Bevan.] 



QUESTIONS TO CHAPTER XXII. 
The Examination of Air, Water, and Food. 

Of what substances in the atmosphere may it be necessary at times 
to obtain the proportion ? How is the proportion of aqueous vapor to 
be determined ? What causes the difference in the readings of the wet- 
and dry- bulb thermometers, and what tables are to be used in conjunc- 
tion with them ? 

How may the presence of ozone in the air be demonstrated ? Upon 
what does the test depend? How might an approximate quantitative 
test of ozone be made ? 

How may the suspended impurities in the atmosphere be collected 
for examination ? Which method requires the least apparatus, etc. ? 
How may the character and nature of the suspended particles be de- 
termined ? How may a quantitative bacteriological examination be 
made? What are some of the advantages of Dr. Dixon's apparatus? 
Of the sugar-filter method? How may pure cultures of micro-organisms 
in the air be obtained ? 

How may the quantity of organic matter in the air be determined ? 
Why do we determine the proportion of carbon dioxide in the air? 
What is Wolpert's method for finding the percentage of this gas, and 
how may this method be simplified ? Upon what does this test depend? 
What precautions must be observed in making the test? What is the 
Angus Smith method for determining the proportion of carbon dioxide? 
How may it be improved? What is the use of the phenol phtlialeine in 
thfi solution ? How is the percentage of carbon dioxide calculated ? 
How is the alkaline solution to be prepared ? 

Upon what does Pettenkofer's method depend ? What apparatus 
and reagents are required? Wh} r must the lime-water be standardized 
each time? What is the value of the oxalic-acid solution? What are 
some good indicators to use in this test ? Why is just twice the volume 
of lime-water introduced into the bottle that is afterward taken from it 
and tested ? What are some of the advantages and disadvantages of 
baryta-water in comparison with lime-water? 

How may the quantity of ammonia in the atmosphere be determined ? 
How may the presence of other gases be shown ? What is the usual test 
for carbon monoxide ? Upon what is Vogel's test based ? Is it a deli- 
cate one ? Why is it usually not necessary to make a quantitative ex- 
amination of the carbon monoxide ? 

What care should be observed in the collection of water for ex- 
amination ? How much will be necessary for the customary tests? 
What notes should be made at the time of collection ? 

What tests require the previous clearing of the water? How are 
the tests for color and turbidity made ? For smell? What indicates 

(439) 



440 QUESTIONS TO CHAPTER XXII. 

the degree of aeration ? What metallic impurities may give a taste to 
the water ? What information as to the source or purity of a water may 
sometimes be given by the smell ? 

What are the solutions needed in the quantitative test for chlorine ? 
What is the strength of each, and what is the relation of the silver- 
nitrate solution to chlorine? What is the use of the. potassium-chromate 
solution? How may the result be expressed? What solutions are used 
in testing for nitrates quantitatively ? Upon what does this test de- 
pend ? What does the depth of color indicate ? What precautions 
must be observed in testing for nitrites ? Is the test a delicate one ? 

In the test for free and albuminoid ammonia, what is the function 
of the ammonium-chloride solution? Of the potassium-permanganate 
solution ? What part of the distillate contains most of the free am- 
monia? When is it evident that the water contains no more ammonia? 

In testing for hardness, why is a standard lime solution necessary ? 
What should be the characteristics of the lather produced by the soap 
solution ? Why is alcohol used as a solvent for the soap ? What is the 
underlying principle of this test ? 

How may lead, copper, or iron be detected in water? How may 
you distinguish between the respective sulphides of the above metals ? 
How may the above test respecting any one of the metals be corrobo- 
rated ? How delicate is the test, as regards lead ? How might a quan- 
titative determination of these metals be made? What is the principal 
reagent used in the test for phosphates ? 

How ma}' a bacteriological examination of water be made ? Where 
is it best to make the inoculations, and why ? What precautions must 
always be observed in such examinations? 

What are some of the characteristics of good milk? What may 
affect its color ? Its reaction ? Its specific gravity ? How is it usually 
sophisticated or adulterated ? How is the percentage of total solids de- 
termined ? Of fats? What would a high percentage of ash indicate? 
Give a test for annatto. For boric acid. 

What are the characteristics of good butter? What is the differ- 
ence between it and oleo-margarine and similar compounds? What two 
kinds of fatty acids does butter-fat contain ? What are some of the 
distinctions between butter-fat and beef-fat or mutton-fat? How is the 
specific gravity of butter-fat determined? The melting-point? The 
percentage of insoluble fatty acids? 

What are some of the properties of good wheat-flour ? Of wheaten 
bread? How is the percentage of gluten in flour determined? The 
presence of added mineral substances? What does a low percentage 
of gluten indicate? In what kind of flour are parasites, etc., found? 
What is a test for alum in bread? Should bread contain any alum? 
What flours or starches may be used to sophisticate wheat-flour? 



CHAPTER XXIII. 

QUARANTINE. 

(By "Walter Wyman, M.D., Surgeon-General United States Marine-Hospital Service, and 
H. D. Geddings, M.D., Passed Assistant Surgeon Marine-Hospital Service.) 

By quarantine is meant the adoption of restrictive measures 
to prevent the introduction of diseases from one country or 
locality into another. The term itself conveys no definite idea, 
being derived through the Italian from the Latin " quadraginta," 
meaning " forty " and implying forty days, — the period of deten- 
tion imposed on vessels by the first quarantines established at 
Venice in 1403. The old significance of the term is entirely 
lost in its present application, which is quite general. Thus, 
besides regular maritime quarantine, mention is often made of 
land, railroad, cattle, shot-gun, house, and even room quaran- 
tines. 

The name of a disease or article of merchandise may be 
used in prefix, as in " yellow-fever quarantine," small-pox, 
cholera, or rag quarantine. Moreover, quarantines are described 
as properly beginning at the port of departure, and as quaran- 
tines of inspection only, the fumigation and detention being 
imposed at some neighboring station. The term, therefore, is 
applied not only to establishments, but indifferently to persons, 
animals, diseases, localities, and measures. 

There is need of a clear understanding with regard to the 
term, for when, as occasionally, quarantine is ridiculed, or the 
assertion is made that the English disbelieve in quarantine, a 
wrong impression will be received, unless it is understood that 
only particular and obsolete forms of quarantine are meant, 
and not quarantine in the broad sense just mentioned. 

The subject admits of two natural divisions — maritime and 
land quarantine ; but before describing them attention is called 
to the following table, containing a list of diseases that are ordi- 
narily found in official quarantine proclamations : — 

(441) 



442 



TEXT-BOOK OF HYGIENE. 



Table XXXII. 

QUARANTINABLE DISEASES. 









Period of Incubation, in Days. 




Shortest. 


Longest. 


Usual. 


Authority and Remarks. 


Plague . . . 
Yellow fever . 

Cholera . . . 
Typhus fever . 
Small-pox . . 
Measles . . . 
Diphtheria . . . 
Typhoid fever 
Scarlet fever . 
Relapsing fever 
Dengue . 






3 

1 

2 
1 
5 

7 
2 
7 
1 
5 
1 


8 
11 

14 
21 
20 
14 
10 
28 
weeks. 
7 
10 


3 to 5 

H 

2 to 4 
5 to 14 

10 

10 

2 to 5 
21 

4 to 7 

6 
5 


Kitisato. 

Da Costa, Bartholow, 

Geddings. 
Bartholow. 
Bristow. 
Da Costa. 
Da Costa. 
Bartholow. 
Bartholow. 
Da Costa. 
Bartholow. 
Bartholow. 


Leprosy. . . 




Undetermined. 



The above list illustrates the growth of the sanitary idea 
and belief in quarantine. For many years, as now at some 
ports, the list was limited to yellow fever, typhus, cholera, and 
small-pox. It was thus limited at Boston prior to 1881, since 
which date diphtheria, scarlet fever, typhoid fever, and measles 
have been added. The statutes of New York define as quaran- 
tinable " yellow fever, measles, cholera, typhus or ship fever, 
small-pox, scarlatina, diphtheria, relapsing fever, and any dis- 
ease of a contagious, infectious, or pestilential character, which 
shall be considered by the health officer dangerous to the 
public health." 

At Gibraltar, the English sanitary authorities include 
dengue and epidemic rose-rash among the diseases subject to 
their quarantine regulations. 

The most recent addition to the list in this country is 
leprosy, to prevent the introduction of which, and in accord- 
ance with a resolution of the American Public Health Associa- 
tion, a prohibitory circular was issued by the Surgeon-General 
of the Marine-Hospital Service, December 23, 1889. 



FOREIGN QUARANTINE. 443 

Other diseases which may properly call for quarantine are 
mumps, whooping-cough, chicken-pox. epidemic dysentery, 
glanders, tetanus, beriberi, epidemic influenza, and pulmonary 
tuberculosis. 

Influenza may be considered quarantinable under certain 
circumstances, a successful quarantine being reported by Dr. 
Trudeau, whose cottage sanitarium, in the Adirondacks. New 
York, was thus kept exempt during the epidemic of 1890. 

With regard to pulmonary tuberculosis the ground is taken 
by the writer that this disease, at least among immigrants, should 
be excluded from the United States by quarantine. 

Foreign Quarantine. 
The object of maritime quarantine being protection against 
the importation of contagious or infectious disease, chiefly from 
abroad, through the medium of vessels, their crews, passengers, 
and cargoes, it is most logical that restrictive measures should 
begin at the port of departure. Following are the regulations 
prepared by the Supervising Surgeon-General United States 
Marine-Hospital Service, and promulgated by the Secretary of 
the Treasury, April 26. 1894. All quarantine regulations are 
subject to occasional revision under the Act of Congress ap- 
proved February 15, 1893. 

TJ. S. Quarantine Regulations to be Observed at Foreign Ports 

and at Sea. 

article i. — bills of health. 
Par. 1. Masters of vessels departing from any foreign port for a 
port in the United States must obtain a bill of health in duplicate, signed 
by the proper officer or officers of the United States, as provided for by 
law. 

The following form is prescribed : — 
Par 2. Bill of health : 

Form No. 1931 a. 

UNITED STATES BILL OF HEALTH. 

Name of vessel, . Nationality. . Rig. . Master, . Ton- 
nage, gross, ; net, . Iron or wood. Number of compartments for cargo, 

; for steerage passengers. ; for crew, . 

Name of medical officer, . 



444 TEXT-BOOK OF HYGIENE. 

Number of officers, . 

Number of crew, including petty officers, . 

Number of passengers, cabin, . 

Number of passengers, steerage, . 

Number of persons on board, all told, . 

Port of departure, . 

Where last from, . 

Number of cases of sickness, and character, during last voyage, • — . 

Vessel engaged in trade, and plies between and . 

Sanitary condition of vessel, . 

Nature, sanitary history, and condition of cargo, . 

Source and wholesomeness of water-supply, . 

Source and wholesomeness of food-supply, . 

Sanitary history and health of officers and crew, . 

Sanitary history and health of passengers, cabin, . 

Sanitary history and health of passengers, steerage, . 

Sanitary history and condition of their effects, . 

Prevailing diseases at port and vicinity, . 

Number of cases and deaths from the following-named diseases during the past two 
weeks : — 

Diseases. No. of Cases. No. of Deaths. 

Yellow fever 

Asiatic cholera 

Cholera nostras, or cholerine 

Small-pox 

Typhus 

Any conditions affecting the public health existing in the port of departure, or 
vicinity, to be here stated, . 

I certify that the vessel has complied with the rules and regulations made under 

the act of February 15, 1893, and that the vessel leaves this port bound for , 

United States of America, via . 

Given under my hand and seal this day of , 189 — . 

(Signature of consular officer :) , 



Par. 3. Yessels clearing from a foreign port for any port in the 
United States, and entering or calling at intermediate ports, must pro- 
cure at all said ports a supplemental bill of health signed as provided in 
Article 1. If a quaran tillable disease has appeared on board the vessel after 
leaving the original port of departure, or other circumstances presumably 
render the vessel infected, the supplemental bill of health should be with- 
held until such sanitary measures have been taken as are necessary. 

The following form is prescribed : — 

Par. 4 : 

Supplemental Bill of Health. 

Port of . 

Vessel , bound from to , U. S. A. 

Sanitary condition of port : . 

State diseases prevailing at port and in surrounding country . 

Number of cases and the deaths from the following-named diseases during the past 
two weeks : — 



FOREIGN QUARANTINE. 



445 



Diseases. 



No. 



No. 
Deaths. 



Remarks. 

(Any condition affecting the public health existing in the 

port, to be stated here. ) 



Yellow fever 

Asiatic cholera 
or cholerine.., 

Small-pox 

Typhus 



Number and Sanitary Condition of Passengers Taken on at this Por 

of Effects. 
Cabin, No. . Sanitary condition and history . 



and Sanitary Condition 



Steerage, No. 



Sanitary condition and history 



(Cancel Form A, B, or C, as the case requires.) 



Form. 

A. — To the best of my knowledge and belief— 

(Form A will be used at intermediate ports 
where the vessel does not enter or clear.) 
B. — I have satisfied myself that — 

(Form B will be used at intermediate ports 
where the vessel enters and clears.) 



no quarantinable disease has appeared 
aboard since leaving . 



C. — Since leaving ■ 



the following quarantinable disease has appeared on board 



and I certify that the necessary sanitary measures have been taken. 

I certify also that with reference to the passengers, effects, and cargo, taken on at 
this port, the vessel has complied with the rules and regulations made under the act of 
February 15, 1893. 

Given under my hand and seal this day of , 189 — . 



(Signature of consular officer :) 



ARTICLE II. — INSPECTION. 

Par. 1. The officer issuing the bill of health will satisfy himself, by 
inspection if necessary, that the conditions certified to therein are true. 
Par. 2. Inspection is required of — 

(a) All vessels from ports at which cholera prevails, or at which 
yellow fever, small-pox, or typhus fever prevails in epidemic form. 

(b) All vessels carrying steerage passengers. 

But the inspection of this class may be limited to said passengers 
and their living-apartments, if from a healthy port. 

Par. 3. Inspection of the vessel is such an examination of the vessel, 
cargo, passengers, crew, personal effects of same, and including exam- 
ination of manifests and other papers, food- and water- supply, as will 
enable him to determine if these regulations have been complied with. 

Par. 4. When an inspection is required, it should be made by day- 
light, as late as practicable before sailing. The vessel should be in- 
spected before the passengers go aboard ; the passengers just before 
embarkation, and the crew on deck ; and no cargo or person should be 
allowed to come aboard after such inspection except by permission of 
the officer issuing the bill of health. 



446 TEXT-BOOK OF HYGIENE. 

ARTICLE III. — REQUIREMENTS WITH REGARD TO VESSELS. 

Par. 1. Vessels, prior to stowing cargo or receiving passengers, shall 
be mechanically clean in all parts, especially the hold, forecastle, and 
steerage ; the bilges and limbers free from odor and deposit. The air- 
streaks should be sufficient in number and open for ventilation. Disin- 
fection of the vessel ma}' be required by the medical officer of the United 
States. 

Par. 2. If any infectious disease has occurred during the last voyage, 
the portions of the vessel liable to have been infected should be disin- 
fected. When required, this should be done by one of the methods 
hereinafter described. 

Par. 3. The air-space and ventilation must conform to the provisions 
of the act of Congress approved August 2, 1882, entitled, " An act to 
regulate the carriage of passengers by sea." 1 

Par. 4. The food- and water- supply should be sufficient, and water 
for drinking purposes, free from possibility of pollution, should be easily 
accessible. 

Par. 5. Vessels departing from a port where cholera prevails should 
have two medical officers, if more than 250 steerage passengers are 
carried. 

Par. 6. All bedding provided for steerage passengers must be de- 
stro} 7 ed or disinfected before being again used or landed, and mattresses 
and pillows used by steerage passengers shall not be landed. 

Par. 7. The hospitals of vessels carrying steerage passengers should 
be located on the upper or second deck, and not in direct communication 
with any steerage compartment. 

Par. 8. Excepting when absolutely required, no solid partitions 
should be placed in any steerage compartment, obstructing light and air. 

ARTICLE IV. — CARGO. 

Par. 1. At ports infected with cholera, earth, sand, loam, soft or 
porous rock should not be taken as ballast. Nor, at ports infected with 
yellow fever, should such ballast be allowed on board vessels clearing for 
ports south of the southern boundary of Maryland, when better material, 
such as hard rock, is obtainable, or when it is possible to use water 
ballast. 

Par. 2. Certain food-products, namely, unsalted meats, sausages, 
dressed poultry, dried and smoked meats, rennets, fresh butter, fresh 
milk (unsterilized), fresh cheese, fresh bread, fresh vegetables, coming 

1 Computation of air-space in any steerage compartment must not include the space 
taken up by bunks, mattresses, life-preservers, or personal effects, 



FOREIGN QUARANTINE. 447 

from cholera-infected localities, or through such localities, if exposed to 
infection therein, should not be shipped. 

Par. 3. Fresh fruits from districts where cholera prevails shall be 
shipped only under such sanitary supervision as will enable the inspector 
to certify that they have not been exposed to infection. 

Par. 4. Articles of merchandise, personal effects, and bedding, 
coming from a district known to be infected, or as to the origin of which 
no positive evidence can be obtained, and which the consular or medical 
officer has reason to believe are infected, should be subjected to disinfec- 
tion prior to shipment by processes prescribed for articles according to 
their class. 

Par. 5. New merchandise in general may be accepted for shipment 
without question ; and articles of new merchandise, textile fabrics, and 
the like, which have been packed or prepared for shipment in an infected 
port or place, with a special view to protect the same from moisture inci- 
dent to the voyage, may be accepted and exempted from disinfection. 

Par. 6. All rags and all textile fabrics used in the manufacture of 
paper, collected or packed in any foreign port or place, must, prior to 
shipment to the United States, be subjected to disinfection by one of the 
prescribed methods : — 

(Old jute bags, old cotton bags, old rope, new cotton and linen 
cuttings from factories not included.) 

Par. 7. Rags, old jute, old gunny, old rope, and similar articles, 
gathered or packed or handled in any port or place where cholera or 
yellow fever prevails, or small-pox or typhus fever prevails in epidemic 
form, should not be shipped until the officer issuing the bill of health 
shall be satisfied that the port or place has been for thirty days free 
from such infection, and after the disinfection of the articles. 

Par. 8. New feathers for bedding ; human and other hair, unmanu- 
factured ; bristles; wool; hides not chemically cured, coming from a 
district where cholera prevails, shall be refused shipment until thirty 
days have elapsed since last exposure, unless unpacked and disinfected 
as hereinafter provided. 

Feathers which have been used should be disinfected, and invariably 
by steam. 

Par. 9. The articles enumerated in the preceding paragraph coming 
from a district where yellow fever prevails, destined for ports or places 
south of the southern boundary of Maryland during the quarantine 
season, or where small-pox or typhus fever prevails in epidemic form, 
should be refused shipment, unless disinfected as hereinafter provided. 

Par. 10. Articles such as gelatin, glue, glue-stock, fish-glue, fish- 
bladders, fish-skins, sausage-casings, bladders, driecl blood, having been 



448 TEXT-BOOK OF HYGIENE. 

in any way liable to infection in the process of preparation, gathering, or 
shipment, should be disinfected. 

Par. 11. Any covering shipped from or through an infected port 
or place, and which the consul or medical officer has reason to believe 
infected, should be disinfected. 

Par. 12. An}' article presumably infected, which cannot be disin- 
fected, should not be shipped. 1 

ARTICLE V. — PASSENGERS AND CREW. 

Par. 1. Passengers, for the purposes of these regulations, are di- 
vided into two classes, — cabin and steerage. 

Par. 2. Xo person suffering from a quarantinable disease, or scarlet 
fever, measles, or diphtheria, should be allowed to ship. 

Par. 3. Steerage passengers and crew, coming from districts where 
small-pox prevails in epidemic form, or who have been exposed to small- 
pox, shall be vaccinated before embarkation, unless they show evidence 
of immunity to small-pox by previous attack or recent successful vaccina- 
tion. 

Par. 4. Steerage passengers and crew who, in the opinion of the 
inspecting officers, have been exposed to the infection of typhus fever, 
should not be allowed to embark for a period of at least foyrteen days 
after such exposure and the disinfection of their baggage. 

Par. 5. When practicable, passengers should not ship from an 
infected port. Steerage passengers coming from cholera-infected dis- 
tricts must be detained five days in suitable houses or barracks located 
where there is no danger from infection, and all baggage disinfected as 
hereinafter provided ; the said period of five da}s to begin only after 
the bathing of the passengers, disinfection of all their baggage and 
apparel, removal of all food brought with them, and isolation from others 
not so treated. 

Par. 6. Steerage passengers from districts not infected with cholera, 
shipping at a port infected with cholera, unless passed through without 
danger of infection and no communication allowed between passengers 
and the infected locality, should be treated as those in the last paragraph. 

Par. 7. Prior to sailing from ports infected with cholera, each pas- 
senger of the cabin class should produce satisfactory evidence as to his 
exact place of abode during the five days immediately preceding embark- 
ation ; and if it appear that he or his baggage has been exposed to con- 
tagion, such passenger should be detained such length of time as shall 
be deemed necessary by the inspecting officer, and the baggage should 
be disinfected. 

1 Upholstered furniture, sheep-skins used as wearing-apparel, bedding, bones, horns, and hoofs. 



FOREIGN QUARANTINE. 44:9 

Par. 8. The rules prescribed for the disinfection of the baggage 
and personal effects of passengers and crew coming from cholera-infected 
ports should also be observed with regard to passengers and crew coming 
from ports and places where plague, yellow fever, typhus fever, or small- 
pox is prevailing in an epidemic form. 

Par. 9. Should cholera break out in the barracks or houses in 
which the passengers are undergoing the five days' observation, no pas- 
senger from said house or barracks should embark until five days' 
isolation from the last case and a repetition of the sanitary measures 
previously taken. 

Par. 10. All baggage of steerage passengers destined for the United 
States shall be labeled. If the baggage has been inspected and passed, 
the label shall be a red label bearing the name of the port, the steam-ship 
on which the baggage is to be carried, the word " inspected" in large 
type, the date of inspection, and the seal or stamp of the consular or 
medical officer of the United States. All baggage that has been disin- 
fected shall bear a yellow label, upon which shall be printed the name of 
the port, the steam-ship upon which the baggage is to be carried, the 
word " disinfected" in large type, the date of disinfection, and the seal 
or stamp of the consular or medical officer of the United States. It is 
understood, and it will be so printed on the blank, that the label is not 
valid unless bearing the consular or medical officer's stamp or seal. 

Par. 11. Each steerage passenger should be furnished with an 
inspection card. This card, stamped by the consular or medical officer, 
is to be issued to every member of a family as well as to the head 
thereof. 

Par. 12. Form of inspection card (see next page). 

Par. 13. Cabin passengers from cholera-infected ports or places 
should be given a special inspection card, on which shall be printed the 
port of departure, name of passenger, name of ship, date of departure, 
and an indicated space for the seal or stamp of the consular or medical 
officer. 

Par. 14. The baggage of such cabin passengers shall be labeled in 
the same manner as steerage baggage. 

Par. 15. In a port where cholera prevails, or where yellow fever 
prevails in epidemic form, the crews of passenger-ships should remain 
on board during their stay. Should additional men be shipped, the 
same precautions should be observed with them as in the case of 
steerage passengers. If it is considered necessaiy, the crews of freight- 
ships may be similarly treated, at the discretion of the medical officer. 

Par. 16. Passengers and crews, merchandise and baggage, prior to 
shipment at a non-infected port, but coming from an infected locality, 



450 



TEXT-BOOK OF HYGIENE. 



INSPECTION C-29S.IF2.D. 

(Immigrants and Steerage Passengers.) 
Date of Departure, 



Port of Departure.... 

Name of Ship 

Xame of Immigrant. 



Last Permanent Residence. 



Inspected and passed at 



Seal or Stamp 
of Consular or Med- 
ical Officer. 




Passed by Immigration Bu- 
reau, port of. 

(Date.) 



(The following to be filled in by ship's surgeon or agent prior to or after embarkation.) 
Ship's list or manifest No. on ship's list or manifest 



Berth No. 



£? a 

•S 2 

a o 

S <o 

$ a 

CO M 



f3 

as 



io<©i>ooai©r-<<MeoTf< 



(Reverse Side.) 

Keep this Card to avoid detention at Quarantine and on Railroads 
in the United States. 



Diese Karte muss aufbewahrt werden, um Aufenthalt an der Quar- 
antine, sowie auf den Eisenbahnen der Y T ereinigten Staaten zu vermeiden. 

Cette carte doit etre conservee pour eviter une detention a la Quar- 
antaine, ainsi que sur les chemins de fer des Etats-Unis. 



Deze kaart moet bewaard worden, ten einde oponthoud aan de Quar- 
antijn, alsook op de ijzeren wegen der Vereenigde Staten te vermijden. 



Conservate questo biglietto onde evitare detenzione alia Quarantina 
e sulle Ferrovie degli Stati Uniti. 

Tento listek musite uschovati, nechcete-li ukaranteny (zastaveni 
ohledne zjisteni zdravi) neb na draze ve spojenych statech zdrzeni byti. 

Tuto kartocku treba trfmat' u sebe aby sa predeslo zderzovanu v 
karantenc aj na zeJeznici ve Spojenych Statoch. 



! p 



j» 


Q 


H 





9 


p- 


8 





00 


P 


B 


£ 





N 


ts 


P* 



FOREIGN QUARANTINE. 451 

should be subject to the same restrictions as are imposed in an infected 
port. 

ARTICLE VI. — REQUIREMENTS AT SEA. 

Par. 1. The master of the vessel should cause the following rules 
(which comprise those recommended by the International Conference at 
Rome, 1885) to be observed during the voyage : — 

(a) The soiled body-linen of passengers and crew suffering from 
infectious disease should be at once immersed in boiling water or in a 
disinfecting solution. 

(6) The water-closets should be washed and disinfected twice a day. 

(c) Rigorous cleanliness and free ventilation should be maintained 
during the voyage on board all ships. 

Par. 2. An inspection of the vessel, including the steerage, should 
be made by the ship's physician once each day. 

Par. 3. Should cholera (or cholerine), yellow fever, typhus fever, 
or small-pox appear on board a ship while at sea, those who first show 
symptoms of these diseases will be immediately sent to the hospital; the 
ship's physician will then immediately notify the captain, and all of the 
effects liable to convey infection which have been in use will be destro} T ed 
or disinfected. 

Par. 4. The compartments occupied by those who fall sick with 
infectious disease should be disinfected, and, as far as possible, the com- 
partments thus disinfected should be freely exposed to the air. If the 
vessel is an iron steamer and the compartments suitable, the entire com- 
partment should be disinfected by steam. The articles liable to convey 
infection should remain in the compartments during the disinfection. 
After disinfection of the compartments the bedding and clothing may be 
removed and dried. 

Par. 5. Patients with infectious disease should be isolated. 

Par. 6. The hospital should be disinfected as soon as it becomes 
vacant. 

Par. f. The dead should be enveloped in a sheet saturated with 
one of the strong disinfecting solutions, without previous washing of the 
body, and at once placed in a coffin hermetically sealed, or buried at sea. 

Par. 8. A clinical record should be kept on the prescribed form, b} T 
the ship's surgeon, of all cases of sickness on board, and delivered to 
the quarantine officer at the port of arrival. 

Par. 9. Under the foregoing paragraphs, disinfecting solutions are 
limited to the following : Strong : acid solution of bichloride of mer- 
cury (1 to 500) ; a 1 to 20 solution of pure carbolic acid. Weak : acid 
solution of bichloride of mercury (1 to 1000) ; pure carbolic acid, 
1 to 40. 



452 TEXT-BOOK OF HYGIENE. 

Par. 10. Form for clinical report 1 : — 



Name. 


Age. 


Sex. 


Last per- 
manent 
residence 


Date of 
admission. 


Disease. 


Dis- 
charged. 


Result. 


































Clinical history. 
































Clinical history. 
































Clinical history. 
































Clinical history. 

















Par. 11. Sailing-vessels leaving ports infected with yellow fever, 
and destined for any port in the United States south of the southern 
boundary of Maryland, which is not provided with proper facilities for 
treatment, shall, during the quarantine period, be directed by the con- 
sular or medical officer to proceed, for disinfection and treatment, to some 
quarantine station in the United States provided with the required 
facilities. 

ARTICLE VII. — DISINFECTION. 

Par. 1. The disinfection of iron vessels shall be as follows : — 

(a) Holds. — After mechanical cleansing, the hold to be thoroughly 
washed with an acid solution of bichloride of mercury 1 to 800 (mercury 
1 part, hydrochloric acid 2 parts, water 800 parts), applied under press- 
ure to all surfaces by means of a hose. 

In case the Disinfection is Required for Yellow Fever. 

If the cargo is so stowed as to admit of disinfection, the hold and 
cargo ma}- be disinfected without breaking bulk, by sulphur dioxide, 10 
per cent, per volume strength, forty-eight hours' exposure for iron and 
seventy-two hours for wooden vessels. 

(b) Steerage and Forecastle. — The same treatment should be given 
the steerage and forecastle as the hold, but when practicable steam disin- 

1 Temperature to be recorded. 



FOREIGN QUARANTINE. 453 

fection of these compartments should be practiced. The temperature in 
all parts of the compartments is to be not less than 100° C. 

(c) Cabins, Officers' 1 Quarters, Staterooms, etc. — The bedding, 
fabrics, and carpets should be removed and disinfected by steam. After 
thorough mechanical cleansing, the exposed surfaces of fabrics which 
cannot be removed should be washed with a solution of bichloride of 
mercury 1 1 to 1000, or 3-per-cent. solution of carbolic acid, both of which 
should be removed, but not under two hours. Afterward the apartments 
should be thoroughly dried and aired. 

Par. 2. The disinfection of wooden vessels is to be accomplished 
as follows : After mechanical cleansing, washing out the bilges until 
clean, etc. (first), by fumigation by sulphur dioxide, 10-per-cent. strength, 
twenty-four hours in the cabin and forecastle and forty-eight hours in the 
hold ; and (second) flushing or washing with acid solution of bichloride 
of mercury in large quantity (1 to 800). The bilges to be first flushed 
with sea-water, pumped out, and then treated with the acid solution of 
bichloride of mercury in large quantity, allowed to remain in long con- 
tact. In addition to the sulphur fumigation of such apartments, the 
cabins, forecastle, and other apartments, and their contents, to be treated 
as those on iron vessels. 

Cargo. 

Par. 3. Disinfection of rags and old jute, etc., shall be by one of the 
following methods : — 

(a) By boiling in water for not less than thirt}' minutes. 

(b) By steam at the temperature of 100° C. for not less than thirty 
minutes after such temperature is reached. 

(c) B}^ exposure for not less than six hours in a closed compartment 
to a 4-per-cent. strength (per volume) of sulphur-dioxide gas, — made by 
burning roll sulphur or by the liberation of liquefied sulphur dioxide, — 
allowance to be made for leakage by increasing the amount of sulphur. 

Par. 4. In all of the above methods, the rags, old jute, etc., must be 
unbaled, and in the disinfection by steam or sulphur the rags must be 
loosely spread on racks (preferably wire netting) in layers of not more 
than six inches in depth, and in such a manner as to insure the diffusion 
of the gas to all parts alike. 

The articles must not at any time occupy more than 50 per cent, of 
the total cubic space, and the exposure to date from the complete com- 
bustion of the sulphur. 

Par. 5. New feathers for bedding shall be disinfected b} T one of the 
following methods : — 

1 Polished metal is injured by mercury, and leather by steam. 



454 TEXT-BOOK OF HYGIENE. 

(a) By steam at a temperature of 100° C. for a period of thirty 
minutes after such temperature has been reached. 

(b) By exposure to sulphur dioxide, 4-per-cent. strength per volume, 
for not less than six hours. 

Par. 6. Human hair or other hair, unmanufactured, and bristles, to 
be disinfected l>3 r sulphur dioxide, 4-per-cent. strength per volume, six 
hours, or, if not clean, by a solution of pure carbolic acid, 4-per-cent. 
strength, the articles to be thoroughly saturated. 

Par. 7. Wool to be disinfected by sulphur dioxide, 4-per-cent. 
strength per volume, for not less than twenty hours, the wool to be un- 
baled and loosely spread on racks, as in the manner provided for the 
disinfection of rags. 

Par. 8. Hides to be disinfected by sulphur dioxide, 4-per-cent. 
strength per volume, for not less than twenty hours, or by thorough 
saturation with a solution of pure carbolic acid, 4-per-cent. strength ; 
hides to be invariably unbaled for the purpose. 

Par. 9. Articles mentioned in paragraph 10, Article IV, should be 
disinfected by being spread on racks and exposed to sulphur dioxide, 
4 per cent, per volume, twenty hours. 

Par. 10. Coverings should be disinfected — 

(a) In the hold, by exposure to sulphur dioxide, 10-per-cent. 
strength per volume, for twelve hours ; the cargo being so stowed as to 
allow access to all parts of such surfaces. 

(b) By breaking bulk and exposure to sulphur dioxide, 4-per-cent. 
strength per volume, for twenty-four hours. 

(c) B} 7 wetting thoroughly with solution of bichloride of mercury 
1 to 800. 

Par. 11. The disinfection of personal effects, prescribed by these 
regulations, should be as follows : — 

(a) Clothing and bedding should be disinfected by (1) exposure 
to steam from 100° to 102° C. for thirty minutes after such temperature 
is reached, or by boiling for thirty minutes ; (2) immersion in bichloride 
solution 1 to 800, or solution of pure carbolic acid, 3 per cent., until 
thoroughly wetted, and allowed to dry before washing. 

This last process (2) to be used only for articles that will be injured 
by steam or boiling. 1 

(b) Cooking and eating utensils should be immersed in boiling 
water. 

Note. — A 4 per cent, per volume strength of sulphur dioxide can be obtained by 
burning not less than 4 pounds 2 ounces of sulphur to each 1000 cubic feet of space ; the 
compartment to be air-tight. 

1 Articles of rubber, leather, celluloid, gutta-percha, hats, furs, skins, and similar arti- 
cles, are injured by steam or boiling. 



FOREIGN QUARANTINE. 455 

A 10 per cent, per volume strength can only be obtained by one of 
the following methods : B3* the use of a special furnace, or b}~ liquefied 
sulphur-dioxide gas. 

ARTICLE VIII. — RECORDS. REPORTS. ETC. 

The officer making* the inspection will preserve in his office a record 
of each inspection made. A copy of said record will be forwarded weekly 
to the Supervising Surgeon-General of the Marine-Hospital Service, at 
Washington. D. C. 

In addition to the duties already prescribed, the medical officer, 
when detailed in accordance with the Act of Cougress approved Febru- 
ary 15. 1893. shall furnish such reports to the Supervising Surgeon- 
General of the Marine-Hospital Service as may be required by the latter. 

XOTES FOR THE INFORMATION OF MASTERS OF TESSELS AND OTHERS. 

Formula for Strong Disinfecting Solutions. 

Bichloride of Mercury. {1 : 500. ) 

Bichloride of mercury 1 part. 

Hydrochloric acid 2 parts. 

Water 500 parts. 

Mix. 

Carbolic Acid. 

Carbolic acid (pure) 50 parts. 

Warm water 1000 parts. 

Formula for Weak Solutions. 
Bichloride of Mercury. (1 : 1000.) 

Bichloride of mercury 1 part. 

Hydrochloric acid 2 parts. 

Water 1000 parts. 

Carbolic Acid. 

Carbolic acid (pure) 25 parts. 

Warm water , 1000 parts. 

Disinfection of Hospitals, Infected Comparments, etc. 

(a) By steam as provided in Article VII, paragraph (c) ; or, when 
steam is not available — 

(b) B3- methods prescribed in Article Til, paragraphs (a) and (c). 
Water-closets, etc., should be disinfected by strong solution of 

bichloride of mercury or carbolic acid. 1 

It is suggested that a vessel should carry, for every 100 passen- 
gers : Bichloride of mercury, 5 pounds; hydrochloric acid. 10 pounds; 
carbolic acid, 10 pounds. 

1 The use of these disinfecting solutions does not preclude the additional use of hypo- 
chlorite of lime. 



456 TEXT-BOOK OF HYGIENE. 

EFFICIENCY OF FOREIGN REGULATIONS. 

The wisdom of this method of procedure and the efficient 
working of these regulations are demonstrated by the following 
statement taken from the report of the medical officer of the 
Marine-Hospital Service on duty at Naples, Italy, where, during 
the summer of 1893, cholera was epidemic : — 

"From the 15th of July to August 17th there were eight 
vessels cleared from Naples with steerage passengers, — four for 
New York and four for South American ports. The first to 
leave was the Karamania, for New York, on July 15th. No 
cholera at that time existed in Naples. The first case occurred 
in Naples on the night of the 16th, and the result of the bac- 
teriological examination was not known until the afternoon of 
the 17th or morning of the 18th. 

" The passengers for the Kararnania and the ship itself 
were put through the established routine. The ship was 
cleaned; ventilation, etc., altered to conform with the United 
States law ; closets and hospitals put in good order ; water- and 
food- supply attended to ; passengers inspected and vaccinated, 
and both their baggage and clothing searched for food. Three 
days after sailing, i.e., on the 18th, a death from cholera 
occurred, and just before reaching New York there were two 
more. It is not unlikely that the infection in the first cases was 
traceable to the same source as those occurring in Naples on 
the 16th. It is more than probable that but for the careful 
exclusion of food brought by passengers there would have been 
more cases on the remaining three ships for the United States. 
The regulations governing infected ports were rigidly enforced. 
The first vessel to leave, four days after the cholera was an- 
nounced, was the Massilia. Her passengers were met at the 
trains and conducted immediately on board ; were there isolated 
three days, and all their baggage transferred across city unopened. 
All food was carefully looked into ; all from persons or baggage 
excluded ; and the baggage of a few, about whose antecedents 
there was doubt, disinfected by steam. The ship was warped 



FOREIGN QUARANTINE. 457 

out some distance from the pier every night, and an inspector 
kept on board night and day. There being no cholera known 
to exist anywhere in Italy outside of Xaples, it was not thought 
necessary to disinfect all baggage or isolate five days. She 
arrived safely in New York without mishap. The remaining 
two for the United States were the Weser and Caslimire ; in 
both cases the regulations were enforced in detail. One lay 
about a mile and a half off shore during her five days. The 
other cruised at sea. In both cases an inspector was kept 
aboard day and night. Both escaped cholera. 

" The four for South America, with the result in each case, 
were as follow : The figures are not official, but are practically 
accurate in every respect. All were turned back by the South 
American authorities : Vencinzio Florio, — about 50 deaths ; 
Andrea Dor'io, — 90 on way out, total not ascertained; El 
Remo, — 84 deaths; Carlo JR., — about 230 deaths. 

" To summarize, then, eight ships left Naples. The water- 
supply was the same and the food about the same ; the class of 
passengers identical, and their places of origin similar, — in 
many cases identical. All four leaving without precautions 
became floating pest-houses. Of the four for the United States, 
the one leaving before cholera appeared in Xaples had 3 deaths ; 
the other three were made to conform to the regulations, and 
all escaped. In other words, every ship that left Naples had 
cholera except those in whose case the ' infected port ' regula- 
tions were carried out ; and of the five that had cholera, the 
only one that escaped with less than 50 deaths was the one on 
which our ; non-infected port ' regulations were enforced, she 
having only 3 deaths en route. In addition, the enforcement 
of the regulations compelled the abandonment of a number of 
other sailings for the United States. The escape of the Massilia, 
Caslimire, and Weser may be ; post,' not ' propter hoc,' but we 
certainly have the right to consider the evidence to be strongly 
on the side of ; propter.' " 



458 TEXT-BOOK OB 1 HYGIENE. 



Domestic Quarantine. 

The trans-oceanic part of the voyage completed, the vessel 
arrives in the waters of the United States, and here she is con- 
fronted by a municipal, State, or national quarantine station, 
where the question will be determined whether the measures 
prescribed have been carried out, whether they have been effect- 
ive in the particular case, and, in fine, whether the vessel, her 
crew, passengers, and cargo are or are not a menace to the 
health of the city and the country at large. 

maritime quarantine stations. 

In describing a maritime quarantine station it should be 
borne in mind that the details in the plant must vary in accord- 
ance with the special demands of each port. 

Thus, it is not to be expected that at Charleston, where 
immigration is limited, there should be the same provisions for 
detention of immigrants as at New York, through whose por- 
tals more than one-third of a million of immigrants pass each 
year ; or San Francisco, where enter the throng of travelers and 
immigrants from the far East. 

We should not expect that Boston, in the more salubrious 
North, would have the means or adopt the practice of discharging 
ballast, cleaning and fumigating every vessel from an infected 
port, which is the invariable custom at Pensacola. 

But, leaving these variations for subsequent notice, the first 
thing to be considered, in the establishment of a complete mari- 
time quarantine, is proper location. This must be at a point 
remote from city or village boundaries, and not likely to be 
encroached upon by urban growth. It should be more or less 
removed from the channels of commerce, and yet be easily 
accessible. Indifference to proper location could very readily 
make the quarantine station a source of danger instead of a 
protection. 



DOMESTIC QUARANTINE. 459 

THE QUARANTINE PLANT. 

The requirements of a maritime quarantine station may be 
enumerated as follows : 1 . A 'boarding-station. 2. A boardinsf- 
vessel. 3. Anchorages. 4. Wharves with warehouse, disin- 
fecting machinery, and machinery for discharge of ballast. 5. 
Lazaretto, or hospital for treatment of contagious diseases. 6. 
Hospital for treatment of non-contagious diseases. 7. Barracks 
for the detention, in groups, of suspects, or persons who have 
been exposed to contagion or infection. 8. Bath-house. 9. 
Water-supply. 10. A cremation furnace. 11. Quarters for 
medical officers. 12. Laundry. 

1. The Boarding-Station. — This includes a boat-house, 
with boatmen's quarters so located as to avoid infection from 
the Lazaretto, and to be within easy reach of passing com- 
merce. 

2. Boarding- Vessel. — The facilities for boarding and in- 
spection will vary with the location of the station, whether 
within the limits of a land-locked harbor or exposed to the full 
force of wind and sea. In the former case a steam- or naphtha- 
launch, or even a row-boat, will suffice ; but in the latter case 
the boarding-boat must be a steamer, preferably of the sea-going 
tug-boat type, for it must be remembered that any delay in 
making the inspection inflicts hardship on commerce, and must 
inevitably produce discontent and complaint. 

3. Anchorages. — Two anchorages, one for infected and 
one for non-infected vessels. The anchorage for the detention 
of the infected vessel should be conveniently removed from the 
main establishment and safely remote from the track of com- 
merce. Its position should be sheltered, and good holding- 
ground for vessels' anchors is of the first importance. The 
channel to the anchorages, and, if necessary, their boundaries, 
should be plainly marked by buoys. 

4. Wharves. — A wharf or pier is a prime essential in the 
equipment of a complete station, and should be located in 
water at least twenty feet deep, and should be of such length 



460 TEXT-BOOK OF HYGIENE. 

that the largest vessels trading* at the port can lie there safely; 
at least, in all ordinary weather. Upon this wharf there should 
be a warehouse for the storage of baggage and portions of 
cargo (practically, cargo is never fully discharged, being disin- 
fected in situ). On the wharf should be placed the steam 
disinfecting chambers, sulphur-furnaces, and tanks for holding 
disinfecting solutions. (At certain stations the disinfecting 
apparatus is necessarily placed on a barge.) When required, 
a special, additional wharf should be provided for the discharge 
of ballast. 

Steam Disinfecting Chambers. — The principle of disinfec- 
tion by steam was first advocated by Dr. A. N. Bell, of Brook- 
lyn ; but the credit of first designing apparatus for the special 
purpose belongs to Dr. Joseph Holt, and his design was subse- 
quently improved upon by Dr. Wilkinson and others. 

Steam Chambers. — These chambers consisted of cylindrical 
shells, made of strong boiler-iron, 40 to 50 feet long and 7 to 8 
feet in diameter (inside measurement), furnished with doors at 
each end. The steam was admitted directly to the interior of 
the chamber, and in addition there was a coil of pipe for the 
application of dry heat. These chambers were fairly efficient 
in action, but there was a great waste of space, and with the 
exercise of every possible care there was always more or less 
wetting of fabrics by the water of condensation. Many im- 
provements have been made from time to time in the construc- 
tion of steam disinfecting chambers, those constructed for the 
national quarantine station at San Francisco, Cal., being of the 
same general construction, but dispensing with the coil of pipe, 
and substituting therefor a jacket surrounding the entire 
chamber. 

The most recent steam chambers are the joint plan of Passed 
Assistant Surgeon J. J. Kinyoun, Marine-Hospital Service, and 
Mr. W. H. Francis, of the Kensington Engine- Works of Phil- 
adelphia. They are of rectangular section, 16 feet in length, 
4 feet 6 inches in width, and 5 feet 6 inches in height, and are 



DOMESTIC QUARANTINE. 461 

provided with steam-tight doors opening at either end. The 
chambers are constructed of an inner and outer steel shell 2| 
inches apart, with cast-iron end frames, intermediate truss bands, 
and of stay-bolt construction. 

The doors have concave steel plates riveted to cast angle 
frames fitted with heavy rubber gaskets ; they are handled by 
convenient cranes, and drawn tight by drop-forged steel eye- 
bolts, swinging in and out of slots in the door-frames. The 
rectangular form is adopted in preference to the round, as it 
gives the most effective space during exposure, with little loss 
of steam, and enables cars on tracks to be readily handled in 
and out. The jacket is used to give perfect circulation and 
distribution of heat, to prevent condensation, and to dry the 
goods exposed. The jackets, which are filled with steam during 
the entire operation of the plant, make the chambers drying 
ovens ; so that the articles to be disinfected are brought to the 
required temperature before the admission of steam to the inner 
chamber, and are thoroughly dried after the steam has been 
exhausted. 

In the experiments of Professor Koch in connection with 
Dr. Wollfhugel it was found that hot air alone, even at a tem- 
perature of 230° to 248° F., after an exposure of three hours, 
would not with certainty destroy bacilli and spores. It is neces- 
sary, therefore, to eliminate the possibility of the pocketing of 
air, or of a mixture of air and steam, during exposure. To 
prevent this a vacuum pump is attached to the system of piping, 
whereby a vacuum of 15 to 20 inches is produced in the 
chamber prior to the admission of steam. In previous chambers 
this important point was neglected, and this accounts for the 
unreliable results obtained by a number of disinfecting plants. 

For convenience of handling the goods to be disinfected, 
each chamber is provided with two cars of light wrought- 
iron construction, with removable trays with bottoms of galvan- 
ized-iron wire netting, and having a series of bronze wardrobe- 
hooks in the top of the frame-work, thus permitting the articles 



462 TEXT-BOOK OF HYGIENE. 

to be laid out upon the trays, or, in the case of finer clothing, to 
be hung upon the hooks. The doors at both ends allow the 
cars to be brought in at one end and removed at the other, thus 
securing complete separation of infected and disinfected articles. 
After exposure the cars, upon being unloaded, are returned to 
the working end of the chamber by means of transfer tables 
and side-tracks, permitting a continuous working of the plant. 

The system of piping is so arranged that steam may be 
admitted to the top or bottom of the chamber at will, through 
several openings, and has perfect circulation. Galvanized-iron 
hoods are placed in the chambers, so that steam is not forced 
directly on the clothing. The chamber is provided with ther- 
mometers to register the temperature, vacuum and steam gauges, 
safety-valves, traps, and is covered with magnesia non-conducting 
covering. 

Sulphur- Furnace. — For a long time the method of sulphur 
fumigation pursued was to put into iron pots a quantity of sul- 
phur varying from three to four pounds to one thousand cubic 
feet, igniting this by means of alcohol, and to place them in the 
hold or apartment to be disinfected. An apparatus was de- 
signed by Passed Assistant Surgeon J. J. Kinyoun, Marine-Hos- 
pital Service, for the purpose of producing S0 2 in greater per- 
centage, and consisted of a furnace built on the reverberatory 
plan, with a series of shelves arranged one above another, each 
shelf carrying a pan of burning sulphur. A forced draught is 
kept up by means of a fan-blower connected at the bottom. 
The draught of air charged from the burning sulphur is made 
to reach and pass over the shelf above by means of apertures 
made by shortening the shelves alternately at their rear and 
front extremities. With an experimental furnace, Dr. Kinyoun 
states that "repeated experiments gave from 14 to 16 per cent, 
of S0 2 , temperature 21° C, while burning sulphur in a closed 
place gave only 6 per cent, at 21° C, — i.e., the air would not 
support the combustion of sulphur above that percentage." 

This has been almost entirely superseded by a furnace that 



DOMESTIC QUARANTINE. 463 

is simpler in construction, and which has given admirable re- 
sults in practice. The furnace is double, and has been provided 
with small fire-boxes at each end, over which are placed two 
shallow cast-iron pans five feet long, and the whole inclosed in 
a frame of sheet-iron. The sulphur is placed in the pans and 
a fire lighted in the furnaces, melting the sulphur, which quickly 
ignites. To prevent too rapid combustion baffle plates are 
arranged, and the proper quantity of air is admitted through 
adjustable valves in the furnace-fronts. The fumes of sulphur 
dioxide thus generated are collected and carried into a reser- 
voir, from which they are sucked by an exhaust fan, and are 
thence forced through piping and large flexible hose to the 
apartment to be fumigated. 

The sulphur-furnace in use at the Louisiana Quarantine 
Station is the same in general principle, with the addition that 
the air supplied to the burning sulphur is aspirated from the 
hold of the vessel, and then forced into the furnace. 

Disinfection by Germicidal Solutions. — The apparatus for 
the use of the disinfecting solutions consist of a tank or tanks 
elevated above the level of the floor of the wharf to a sufficient 
height to force the solution through a hose and nozzle to the 
parts of the ship to be reached. The tank is to be filled by a 
steam-pump, and the solution is easily made by surmounting 
the tank with a keg perforated by numerous holes, in which keg 
the powdered bichloride is to be put, and the water for filling 
the tank pumped over it. 

It is a much better plan to have the bichloride solution 
distributed by means of a special pump (made of iron to pre- 
vent amalgamation), as, with the pressure of the pump behind 
it, it penetrates much more deeply into cracks and crevices 
and, in fact, knocks the dirt and filth out of them. 

5 and 6. Hospitals. — The propriety of having separate 
hospitals for contagious and non-contagious diseases is so 
obvious that it need not be dwelt on here, and the necessity 
of a separate establishment for suspects, until the nature of 



464 TEXT-BOOK OF HYGIENE. 

their complaint can be positively made out, is patent and 
only in accord with expediency and the ordinary instincts of 
humanity. 

7. Barracks.— Barracks for the detention of suspects are 
not an essential part of the equipment of every quarantine 
station, but are a necessity only at such stations as are situated 
at the great ports of entry, which are the ports of arrival of the 
vast hordes of immigrants who seek our shores. Barracks are 
an indispensable adjunct in the management of ship-loads of 
immigrants suspected of being infected with cholera, typhus 
fever, and small-pox, and would be required in the case of 
yellow fever but for the fact that there is little or no immigration 
from the yellow-fever zone. 

The barracks should be commodious, substantial, and yet 
of simple and inexpensive construction. They should be well 
ventilated and so arranged that every part of the building is 
under constant surveillance, and so subdivided that the inmates 
are divided into small groups and intercourse between the 
groups prevented. The immigration law requires that the im- 
migrants shall be listed and arranged in groups of thirty, and it 
would be well that this number be preserved as the unit for 
segregation. The barracks should be furnished with bunks, 
arranged in tiers one above the other, and furnished with bed- 
ding of a simple and inexpensive character. 

Clothing of a simple but sufficient kind, and capable of 
easy laundering, should be provided in sufficient quantity to 
furnish each inmate of the barracks with a change while his or 
her own personal effects are undergoing the process of disinfec- 
tion. Attached to the barracks there should be a kitchen, 
thoroughly equipped with all the facilities for furnishing hot 
food of a simple character for the number of inmates provided 
for by the barracks. Dining-rooms should be arranged, and 
special care should be taken to prevent the carrying of any food 
into the barracks. It is perhaps needless to say that, in the 
barracks, the sexes should be separated, and the better arrange- 



DOMESTIC QUARANTINE. 465 

ment is to have two buildings, — one for men and one for women 
and children. 

Latrines. — Latrines of ample size should be provided, and 
should be so arranged that all dejecta may be received into 
metallic vessels containing a germicidal solution of acknowl- 
edged potency ; or, if the dejecta are to be received into a sewer, 
there should be some provision made for their complete disin- 
fection prior to their discharge into the sea or a cess-pool. 

8. Bath-House. — Bathing facilities are an important part 
of the equipment of a quarantine station designed for the hand- 
ling of large numbers of suspects. The best form of bath for 
the purpose is the shower- or rain- bath, it being more easily 
managed, more expeditious, and probably more efficacious than 
the tub-bath. The bath-house should be provided with a room 
for disrobing, from which the suspects will pass into the bathing- 
stalls proper, and there receive a bath the temperature of which 
is under the sole control of the bath-attendant. From the bath 
the suspect will pass into a robing-room, where he will be given 
a suit of sterile clothing, while the clothing which was re- 
moved in the disrobing-room is carried by proper attendants to 
the disinfecting apparatus, there to be rendered safe by steiiliza- 
tion. 

9. Water-Supply. — An abundant supply of pure water is 
not only a desideratum, but a prime necessity, at all quarantine 
stations where it is designed to accommodate cholera suspects. 
It would be desirable to provide a supply of twenty gallons per 
capita per day, and no arrangement will probably give such 
good results as the sinking of an artesian well, if the nature of 
the soil and the geological formation permit. If it is imprac- 
ticable to sink such a well, the next best plan would be to 
arrange for the distillation or sterilization, by boiling, of a suffi- 
cient quantity of water for drinking purposes. 

10. Crematory. — A crematory is a desirable part of the 
equipment of every quarantine station, as it admits of no argu- 
ment that cremation is the best possible method of disposing of 



4:66 TEXT-BOOK OF HYGIENE. 

the bodies of those dead of contagious or infectious disease. In 
addition, it would be desirable that all garbage and waste about 
a quarantine station be incinerated to prevent the possibility of 
infection. 

11 and 12. Detailed description of quarters for medical 
officers and of laundry is unnecessary. 

Having thus considered the necessities and the desiderata in 
the equipment of a quarantine station, it is now proper to con- 
sider the regulations governing them, and for this purpose are 
here appended the regulations prepared by the Supervising 
Surgeon-General of the Marine-Hospital Service, and pro- 
mulgated by the Secretary of the Treasury on April 26, 1894. 
These regulations are to be considered a minimum for the 
stations under municipal and State control, some of which have 
additional requirements : — 

Quarantine Regulations to be Observed at Ports and on the 
Frontiers of the United States. 

preamble. 

1. At or convenient to the principal ports of the United States, 
quarantine stations should be equipped with all appliances for the inspec- 
tion and treatment of vessels, their passengers, crews, and cargoes. 

2. At all other ports where such provisions have not been made, 
inspection stations should be maintained. 

3. An inspection service should be maintained at every port 
throughout the year. 

4. At a fully-equipped quarantine station there should be adequate 
provision for boarding and inspection, apparatus for mechanical cleaning 
of vessels, apparatus for steam disinfection, apparatus for disinfection 
with sulphur dioxide, apparatus for disinfecting solutions, hospitals for 
contagious and doubtful cases, detention barracks for suspects, bathing 
facilities, crematory, and sufficient supply of good water. 

5. The personnel of quarantine stations in the } r ellow-fever zone 
and on fruiters bound for Southern ports should be immune against 
yellow fever. 

6. At quarantine stations all articles liable to convey infection 
should be handled only by the employes of said station, unless the ser- 
vices of the crew are indispensable. 



DOMESTIC QUARANTINE. 467 

7. "Vessels having been treated at national quarantine stations that 
are located a considerable distance from the ports of entry of said vessels 
may be inspected by the local quarantine officer, and, if for any sanitary 
reason it is considered inadvisable to admit the vessel, he should report 
the facts immediately b}^ telegraph, when possible, to the Supervising 
Surgeon-General Marine-Hospital Service, detaining the vessel pending 
his action. 

8. The following regulations are the required minimum standard, 
and do not prevent the addition of such other rules as, for special reasons, 
may be legally made by State or local authorities. 

ARTICLE I. INSPECTION. 

1. Vessels arriving at ports of the United States under the follow- 
ing conditions shall be inspected by a quarantine officer prior to entiy : — 

A. Any vessel with sickness on board. 

B. All vessels from foreign ports. 

C. Yessels from domestic ports where cholera or j^ellow fever 
prevails or where small-pox or t} r phus fever prevails in epidemic form. 

Exceptions. — Vessels not carrying passengers on inland waters of 
the United States. Vessels from the Pacific and Atlantic coast of Brit- 
ish America, provided they do not carry persons or effects of persons 
non-resident in America for the sixty daj T s next preceding arrival, and 
provided always that the port of departure be free from quarantinable 
disease. Vessels from other foreign ports via these excepted ports shall 
be inspected. 

D. Vessels from foreign ports carrying passengers having entered 
a port of the United States without complete discharge of passengers and 
cargo. Such vessels shall be subject to a second inspection before enter- 
ing any other port. Vessels from ports suspected of infection with yellow 
fever, having entered a port north of the southern boundary of Maryland 
without disinfection, shall be subjected to a second inspection before 
entering any port south of said latitude during the quarantine season of 
such port. 

2. The inspections of vessels required by these regulations shall be 
made by daylight, except in case of vessels in distress. 

3. In makipg the inspection of a vessel, the bill of health and clin- 
ical record of all cases treated during the voj^age, crew and passengers' 
lists and manifests, and, when necessary, the ship's log shall be examined. 
The crew and passengers shall be mustered and examined and compared 
with the lists and manifests, and any discrepancies investigated. 

4. No person except the quarantine officer, his employe's, United 
States customs officers, or agents of the vessel, shall be permitted to 



468 TEXT-BOOK OF HYGIENE. 

board any vessel subject to quarantine inspection, until after the vessel 
has been inspected by the quarantine officer and given its discharge. 

ARTICLE II. — QUARANTINE. 

1. For the purpose of these regulations, the quarantinable diseases 
are cholera (cholerine), yellow fever, small-pox, typhus fever, and leprosy. 

2. Vessels arriving under the following conditions shall be placed 
in quarantine : — 

A. With quarantinable disease on board. 

B. Having had such on board during the voyage or within thirty 
da} r s next preceding arrival; or, if arriving in the quarantine season, 
having had yellow fever on board after March 1 of the current year, 
unless satisfactorily disinfected thereafter. 

C. From ports infected with cholera, or where typhus fever pre- 
vails in epidemic form, coming directly or via another foreign port, or 
via United States ports, unless they have complied with the United States 
quarantine regulations for foreign ports ; also vessels from non-infected 
ports, but bringing persons or cargo from places infected with cholera, 
3 T ellow fever, or where typhus fever prevails in epidemic form, except as 
subsequently noted. 

D. From ports where yellow fever prevails, unless disinfected in 
accordance with these regulations, and not less than five days have 
elapsed since such disinfection. 

Exceptions. — The following exceptions may be made to Rules C 
and D with regard to vessels from ports quarantined against on account 
of yellow fever : — 

(a) Vessels arriving during certain seasons of the year — to wit, 
from November 1 to May 1 — may be admitted to entry. 

(b) Vessels bound for ports in the United States north of the 
southern boundary of Maryland, with good sanitary condition and his- 
toiy, having had no sickness on board at ports of departure en route or 
on arrival, provided they have been five days from last infected or sus- 
pected port, may be allowed entry at port of destination. But if said 
vessels carry passengers destined for places south of this latitude the 
baggage of said passengers shall be disinfected. 

In making an inspection of a vessel, if from a port where yellow 
fever prevails, and between May 1 and November 1 of any }^ear, the 
inspector shall ascertain the destination of each passenger thereon, and 
if bound for places south of the southern boundary of Maryland the 
baggage of such passenger shall be disinfected according to the rules 
for such articles infected with yellow fever. Such baggage shall be 
labeled. 



DOMESTIC QUARANTINE. 469 

(c) Vessels engaged in the fruit trade from ports declared safe for 
this purpose by the Supervising Surgeon-General Marine-Hospital Ser- 
vice may be admitted to entry without detention, provided that they 
carry no passengers and have carried no passengers from one port to 
another and have no household effects or personal baggage in cargo, and 
have complied with the special rules and regulations made by the Sec- 
retary of the Treasury with regard to vessels engaged in said trade. 

3. All persons arriving on vessels having had small-pox on board 
must be vaccinated or show satisfactory evidence of recent vaccination 
or of having had small-pox, or be detained in quarantine for not less 
than fourteen days, and all effects and compartments liable to convey 
infection disinfected. 

4. All passengers occupying apartments other than first or second 
cabin shall be vaccinated prior to entry, unless they can show that they 
have had small-pox, or have been recently successfully vaccinated, or be 
detained in quarantine fourteen days. 

5. Vessels arriving at quarantine with leprosy on board shall not 
be granted pratique until the leper with his or her baggage has been 
removed from the vessel to the quarantine station. 

Xo case of leprosy will be landed. 

If the leper is an alien passenger and the vessel is from a foreign 
port, action will be taken as provided by the immigration laws and regu- 
lations of the United States. 

If the leper is an alien and a member of the crew and the vessel is 
from a foreign port, said leper shall be detained at the quarantine at the 
vessel's expense, until taken aboard by the same vessel when outward 
bound. 

ARTICLE in. — GENERAL REQUIREMENTS AT QUARANTINES. 

1. Pilots bringing infected vessels will be detained in quarantine a 
sufficient time to cover the period of incubation of the disease for which 
the vessel is quarantined, if, in the opinion of the quarantine officer, 
such pilots have been exposed to infection. The dunnage of pilots shall 
be disinfected when necessaiy. 

2. Xo direct communication shall be allowed between quarantine, or 
any vessel in quarantine, and any person or place outside, and no com- 
munication except under the supervision of the quarantine officer. 

3. Xo ballast shall be allowed to leave the quarantine station, 
unless disinfected. 

4. Where it is impossible to disinfect cargo in situ, it shall be re- 
moved and disinfected in the manner provided for articles of their class 
in these regulations ; such articles to be unpacked and so arranged as to 



470 TEXT-BOOK OF HYGIENE. 

allow the disinfectant used to reach every part of all surfaces of said 
articles. 

5. Vessels arriving at any port of the United States with cholera 
or yellow fever aboard during the quarantine season shall be remanded 
to an anchorage set apart for infected vessels, there to remain until after 
the discharge of the passengers and purification of the vessels. 

6. All passenger baggage disinfected under the requirements of 
these regulations shall be labeled. 

ARTICLE IV. — TREATMENT IN QUARANTINE OF CHOLERA-INFECTED VESSELS. 

1. x Remove all passengers from the vessel and all of the crew (if 
cholera has occurred on board) save those necessary to care for her. 
Place the sick in hospital and carefully isolate those specially suspected. 
Segregate the remainder in small groups. No communication shall be 
held between these groups. Those believed to be especially capable of 
conve} T ing infection must not enter the barracks until they are bathed 
and furnished with sterile clothing ; nor shall any material capable of 
convejdng infection be taken into the barracks, especially food. 

2. If cholera has occurred in the steerage, all occupants thereof 
must be bathed and their clothing disinfected. 

3. At once proceed with the disinfection of the hand-baggage. 

4. All baggage and effects accompanying steerage passengers, and 
any other baggage or effects that may have been exposed to infection, 
must be disinfected. 

5. Such articles of cargo as are liable to convey infection must be 
disinfected. 

6. All living-apartments and furniture and such other portions of a 
vessel as are liable to convey infection shall be disinfected. 

7. On cholera-infected vessels the water-supply must be changed 
without delay, the casks or tanks disinfected by steam or 10-per-cent. 
solution of potassium permanganate, and after thorough rinsing refilled 
from a source of undoubted purity, or the water supplied must have 
been recently boiled. 

8. Nothing shall be thrown overboard from a cholera-infected vessel, 
not even deck sweepings. Such things shall be burned in the furnace or 
in a place specially designated, but not in the galley. 

ARTICLE V. — DISINFECTION, ETC. 

1. Holds. — The disinfection of iron vessels shall be as follows : — 
(a) With cargo : If cargo is so stowed as to admit of disinfection, 
it and the hold may be disinfected without breaking bulk, except to such 

* It is required only if cholera has occurred on board. 



DOMESTIC QUARANTINE. 471 

a degree as to make disinfection practicable, by sulphur dioxide, 10 per 
cent, per volume strength, for not less than twenty-four hours' exposure. 
(b) Without cargo: After mechanical cleansing, the hold (1) to be 
thoroughly washed with an acid solution of bichloride of mercury 1 to 
800 (mercury 1 part, hydrochloric acid 2 parts, water 800 parts), applied 
under pressure to all surfaces by means of a hose ; (2) by sulphur dioxide, 
10 per cent, per volume strength, for twenty-four hours. 

2. Steerage and Forecastle. — When possible to obtain it — 

(a) The steerage and forecastle shall be disinfected by steam ; the 
temperature in all parts of these compartments to be not less than 100° 
C. for not less than thirty minutes after such temperature has been 
reached. 

(b) When steam cannot be obtained these compartments shall be 
treated in the same manner as required in the disinfection of the empty 
hold. 

3. All bedding and furnishings of the steerage and forecastle to be 
left in place during the disinfection by steam. 

If steam disinfection of steerage is not used, such articles must be 
removed under the strictest sanitary precautions for disinfection by steam 
or burning. 

4. The bedding, fabrics, and carpets should be removed and disin- 
fected by steam or by boiling. After thorough mechanical cleansing the 
woodwork and all other exposed surfaces shall be washed with an acid 
solution of bichloride of mercuiy 1 to 1000, or a 3-per-cent. solution of 
pure carbolic acid. Fabrics which cannot be removed shall be thoroughly- 
saturated with a solution of bichloride of mercury 1 to 1000, or a 3-per- 
cent, solution of pure carbolic acid. 

5. The water ballast of a vessel coming from a cholera-infected port 
should be discharged at sea, or, if discharged in fresh or brackish water, 
must be previously disinfected. The tanks to be flushed and refilled 
with sea-water or disinfected. 

6. For a wooden vessel the treatment is as above, except that ex- 
posure of the hold and living-apartments to sulphur dioxide, 10-per-cent. 
volume, must precede the other treatment. This exposure must be, for 
the hold, forty-eight hours, and for living-apartments twelve hours. 

7. All solid ballast to be discharged or disinfected previous to dis- 
infection of hold. All ballast discharged in fresh water to be disinfected 
by saturation with, or immersion in, an acid solution of bichloride of 
mercuiy 1 to 800. Clear, hard, close-grained rock may be permitted to 
remain on board, but only after disinfection by immersion in an acid solu- 
tion (1 to 800) of bichloride of mercury. Ballast removed from vessels 
must not be taken from the quarantine station. 



472 TEXT-BOOK OF HYGIENE. 

ARTICLE VI. — DETENTION OF PASSENGERS ON ACCOUNT OF CHOLERA. 

1. The people detained shall be inspected by the physician twice 
daily, and be under his constant surveillance, and no intercourse will be 
allowed between different groups while in quarantine. 

2. No direct communication shall be allowed between any person 
detained in quarantine and any one not in quarantine, except through the 
quarantine officer or, by his order, through his agents. 

3. The water- and food- supply will be strictly guarded to prevent 
contamination, and issued to each group separately. 

4. Food of a simple character, sufficient in quantity, thoroughly 
cooked, shall be issued to those detained in quarantine. No fruit shall 
be permitted. 

5. Cleanliness of quarters and of persons shall be enjoined and 
enforced daily. Disinfection shall be used where there is any possibility 
of infection. 

6. Water-closets, urinals, privies, or troughs shall be provided, and 
their contents disinfected before they are discharged, 

7. In any group in which cholera appears, the sick will be imme- 
diately isolated in hospital, and the remaining persons in the group shall 
be bathed and their effects be disinfected ; then removed to other quarters, 
if possible, and the compartment disinfected. 

8. No direct communication shall be allowed between the physician 
and attendants of the hospital and those detained in quarantine. 

No persons shall be discharged from quarantine until five days have 
elapsed since the last exposure to infection and a final disinfection of 
such effects as were taken to barracks. 

No convalescent from cholera shall be discharged from quaran- 
tine until after a sufficient time has elapsed to insure his freedom from 
infection. 1 

9. The body of no person dead of cholera shall be allowed to pass 
through quarantine. The body should be cremated if practicable. If 
not, it should be wrapped, without preliminary washing, in a sheet satu- 
rated with a solution of bichloride of mercury 1 to 500, and buried, 
surrounded by caustic lime. 

ARTICLE VII. — DISINFECTION OF PERSONAL EFFECTS OF PASSENGERS AND 

CREW AND CARGO. 

1. Clothing, bedding, and articles not injured by steam shall be 
disinfected — 

(a) By exposure to steam at a temperature of 100° to 102° C. for 
thirty minutes after such temperature has been reached. 

1 To be determined by bacteriological examination. 



DOMESTIC QUARANTINE. 473 

(6) By boiling for fifteen minutes ; all articles to be submerged. 
(c) By a thorough saturation in a solution of bichloride of mer- 
cury 1 to 1000, and allowed to dvy before washing. 

2. Articles injured by steam (rubber, leather, etc.) and containers, 
to the disinfection of which steam is inapplicable, shall be disinfected by 
thoroughly wetting all surfaces with a solution of bichloride of mercury 
1 to 800, or a 5-per-cent. solution of carbolic acid, and allowed to dry in 
open air. 

3. Cooking and eating utensils, by immersing in boiling water or 
steam. 

4. All rags and old textile fabrics used in the manufacture of paper, 
and all old gunny, old jute, etc., fit only for remanufacture, gathered, col- 
lected, packed, or handled in any port or place where cholera (cholerine) 
or yellow fever exists, or where small-pox or typhus fever prevails in 
epidemic form, and for thirty days after the port or place shall be 
officially declared free from such diseases or epidemic, shall be denied 
entry into any port of the United States. 

5. No rags or old textile fabrics used in the manufacture of paper, 
or articles enumerated in the preceding paragraph, which have not been 
disinfected in accordance with Article VII, paragraph 3, of the " United 
States Quarantine Regulations for Foreign Ports," shall be admitted 
into the United States. 

(Old jute bags, old cotton bags, old rope, new cotton and linen 
cuttings from factories, not included.) 

ARTICLE VIII. — TREATMENT OF VESSELS INFECTED OR SUSPECTED OF 
BEING INFECTED WITH YELLOW FEVER. 

1. Where practicable, at once remove the sick to hospital; remove 
and isolate all persons not required for the care of the vessel. 

2. If the hold is deemed infected, there shall be a preliminary dis- 
infection as hereinafter provided. 

3. The bilge should be cleansed with sea-water, if possible, before 
disinfection, and the hold rendered mechanically clean. 

4. All ballast, except close-grained, hard rock, must be discharged. 
This may be retained aboard if disinfected by immersion in an acid solu- 
tion of bichloride of mercury 1 to 800. 

5. After discharge or disinfection of ballast the vessel should be 
disinfected. 

6. If it is so stowed as to admit of disinfection, the cargo and the 
hold may be disinfected without breaking bulk, except to such a degree 
as to render disinfection practicable. 

It shall be as follows : — 



474 TEXT-BOOK OF HYGIENE. 

Holds to be treated with sulphur dioxide, 10-per-cent. strength per 
volume, forty-eight hours' exposure for iron vessels, seventy-two hours' 
exposure for wooden vessels. 

7. Empty holds to be disinfected as follows : — 

(a) If of iron, by sulphur-dioxide gas, 10-per-cent. strength per 
volume, for twelve hours' exposure, followed by washing with an acid 
solution of bichloride of mercury 1 to 800, applied under pressure to all 
surfaces by means of a hose. 

(b) If of wood, by the same methods as the preceding, save that 
exposure to sulphur-dioxide gas shall be for forty-eight hours ; air-strakes 
to be open. 

8. Cabin, forecastle, etc., after mechanical cleansing, to be first 
treated with sulphur dioxide, not less than 6-per-cent. strength per vol- 
ume, twentj'-four hours' exposure. Then (after cleansing with water, if 
desired) wash all exposed surfaces with a solution of bichloride of mer- 
cury 1 to 800, or 3-per-cent. pure carbolic acid. 

9. Clothing, bedding, and all fabrics which can be removed, not 
injured by steam, shall be disinfected — 

(a) By exposure to steam at a temperature of 100° to 102° C. for 
thirty minutes after such temperature has been reached. 

(6) By boiling for fifteen minutes ; all articles to be submerged. 

(c) By a thorough saturation in a solution of bichloride of mercury 
1 to 1000, and allowed to dry before washing. 

10. Articles injured by steam (rubber, leather, etc.) and containers, 
to the disinfection of which steam is inapplicable, shall be disinfected by (a) 
thoroughly wetting all surfaces with a solution of bichloride of mercury 
1 to 800, or a 5-per-cent. solution of pure carbolic acid, and allowed to 
dry in open air ; or (b) by exposure to the sulphur fumigation, in cabin, 
forecastle, or hold. 

11. The personnel of the vessel shall be detained five days from 
completion of the disinfection. 

12. If the vessel has been disinfected under the supervision of an 
accredited medical officer of the United States at the port of departure, 
the period of quarantine may date from completion of such disinfection, 
and shall not be less than five days. 

ARTICLE IX. — PASSENGER TRAFFIC. 

Passenger traffic may be allowed during the quarantine season from 
any port infected with yellow fever to any port of the United States 
south of the southern boundary of Maryland, under the following con- 
ditions : — 

(a) Vessels to be of iron and clean immediately prior to taking on 
passengers. 



DOMESTIC QUARANTINE. 475 

(b) The vessel must lie at moorings in the open harbor and not ap- 
proach the wharves, nor must the crew be allowed ashore at the port of 
departure. 

(c) All passengers and crew must be immune to yellow fever, and 
so certified by the United States medical officer. 1 

(d) All baggage which has not been disinfected at the port of de- 
parture by the United States medical officer, or which is not in bond for 
points north of the southern boundary of Maryland, shall be disinfected 
at the quarantine at the port of arrival ; no bedding or household effects 
to be allowed to enter. 

ARTICLE X. — MISCELLANEOUS. 

1. The treatment of vessels infected with typhus fever shall be the 
same as that prescribed for yellow fever. 

2. The detention of passengers and crew for small-pox and typhus 
fever shall cover the period of incubation of the disease, the time of 
detention to commence from the date of last exposure ; typhus fever, not 
less than twenty days ; small-pox, not less than fourteen days. 

3. Vessels detained at any national quarantine will be subject to 
such additional rules and regulations as ma} T be promulgated from time 
to time by the Supervising Surgeon-General. 

4. The following is the form of certificate which shall be issued 
to the vessel by the health officer when she is released from quaran- 
tine : — 



189- . 



I certify that , of , from , has in all respects complied with the 

quarantine regulations prescribed by the Secretary of the Treasury, and that in my 
opinion she will not convey quarantinable disease. Said vessel is this day granted free 
pratique. 

Health {Quarantine) Officer, 

Port of . 

ARTICLE XI. — INSPECTION OF STATE AND LOCAL QUARANTINES. 

In the performance of the duties imposed upon him hy the act of 
Februar}^ 15, 1893, the Supervising Surgeon-Greneral of the Marine-Hos- 
pital Service shall, from time to time, personally or through a duly- 
detailed officer of the Marine-Hospital Service, inspect the maritime 
quarantines of the United States, State and local, as well as national, for 
the purpose of ascertaining whether the quarantine regulations prescribed 
hy the Secretary of the Treasury have been or are being complied with. 

1 The evidence of immunity which may be accepted by the sanitary inspector is : First. 
Proof of continued residence in an endemic focus of yellow fever for ten years. Second. 
Proof of previous attack of yellow fever. 



476 TEXT-BOOK OF HYGIENE. 

The Supervising Surgeon-General, or the officer detailed by him as in- 
spector, shall at his discretion visit an y incoming vessel, or any vessel 
detained in quarantine, and all portions of the quarantine establishment, 
for the aforementioned purpose, and with a view to certifying, if need be, 
that the regulations have been, or are, being enforced. 

ARTICLE XII. — CANADIAN AND MEXICAN FRONTIERS. 

1. When practicable, alien immigrants arriving at Canadian and 
Mexican ports, destined for the United States, shall be inspected at the 
port of arrival by the United States consular or medical officer, and be 
subjected to the same sanitary restrictions as are called for by the rules 
and regulations governing United States ports. 

2. Inspection cards will be issued, by the consular or United States 
medical officer at the port of arrival, to all such alien immigrants, and 
labels affixed to their baggage, as is required in the case of those coming 
direct from foreign ports to any port of the United States. 

3. Whenever alien immigrants are not inspected at the port of 
arrival b}< the United States consular or medical officer, they shall enter 
the United States through certain designated places on the frontier, 
where they shall be inspected for the purpose of preventing the intro- 
duction of quarantinable disease. This inspection shall be held by 
daylight. 

4. If any person be found suffering from a quarantinable disease, 
or presumably infected, he shall be denied entry so long as danger of 
conve} T ing the infection exists. 

5. Any baggage or other effects believed to be infected shall be 
refused entry until made safe by a proper disinfection. 

6. Persons coming from localities where small-pox is prevailing in 
epidemic form shall not be allowed entry without vaccination, unless 
they are protected by a previous attack of the disease or a recent 
successful vaccination. 

7. Persons coming from localities where typhus fever prevails in 
epidemic form shall not be allowed entiy until they have been away 
from such locality fonrteen days and their baggage disinfected. 

8. During the quarantine season persons coming from places where 
yellow fever prevails will not be permitted to enter until they have been 
away from such localhVy five days and their baggage has been disinfected. 
But persons immune to yellow fever will not be detained. 

9. No common carrier which is infected, or suspected of being 
infected, shall be allowed to enter the United States until after such 
measures have been taken as will render it safe. 

10. Articles of merchandise, personal effects, etc., which are capable 



MANAGEMENT OF A QUARANTINE STATION. 477 

of conveying infection, and which are presumably infected, shall not be 
allowed entry into the United States until after disinfection. 

11. The methods of disinfection shall be those prescribed in the 
Rules and Regulations made for the maritime quarantines of the United 
States. 

Immigrants who, with their baggage, have been inspected at a port 
of the United States by a quarantine officer upon landing, will be exempt 
from further quarantine inspection when re-entering the United States 
from Canada, unless there is reason to believe that disease has developed 
among such immigrants since such landing and inspection. 

It is the intention of the act of February 15, 1893, under 
which these regulations were framed, to have them act uni- 
formly and without discrimination against any place, and at the 
same time to not interfere with the operation of any additional 
regulations imposed by State or local authority. 

MANAGEMENT OF A QUARANTINE STATION. 

Inspection. — Upon the arrival of a vessel at a quarantine 
station, during the active quarantine season, she should be 
boarded without delay, and the following general routine fol- 
lowed, with such modifications as may be demanded by the 
local conditions or dictated by the experience of the quarantine 
officer. In the event of the arrival of several vessels at the 
same time, they should, as a rule, be boarded as nearly as pos- 
sible in the order of their arrival, the rule of " first come, first 
served " being observed ; though it may be remarked that, in 
the event of the arrival, at nearly the same time, of a vessel 
carrying passengers and one carrying cargo only, there will 
usually be little opposition on the part of ship-masters if the 
passenger-ship is inspected first. Arrived on board, it is 
well to demand the immediate attendance of the master, not 
only from the fact that all information must be sought from 
him, but to impress all concerned with the fact that the author- 
ity of the boarding-officer is, for the time, absolute. The master 
should then be required to produce for inspection his bills of 
health, the ship's manifest, and the crew- and passenger- lists, 



478 TEXT-BOOK OF HYGIENE. 

if the ship carry passengers. These should be carefully scru- 
tinized, the number of crew and passengers being noted or 
borne in mind, and note being made of any articles of cargo 
that come within the proscription of the regulations. All 
special consular certificates bearing on doubtful articles of cargo 
had better be looked into at this time. A careful inspection of 
the ship should now follow, particular attention being paid to 
the condition of the living-apartments of the officers and crew, 
as their condition of cleanliness or the reverse sometimes forms 
an important index to the cleanliness of the whole ship. The 
hatches should be removed, and such portions of the cargo as 
come directly under them be subjected to scrutiny. If the 
vessel is in ballast, the hold should be entered, explored, and 
mental note made of the condition of the ship's inner planking 
or skin, whether dry and sound or rotten and damp. If pos- 
sible, a limber plank should be lifted, and the condition of the 
bilges noted. In the comparatively inaccessible places fore and 
aft there will likely be found deposits of trash and filth, and 
the chain-lockers should be carefully examined to see whether 
the cables have been properly washed prior to stowing, as there 
is good reason to believe that the harbor-mud of certain ports, 
notably Havana, is dangerous. The inspection of the ship 
proper completed, the inspection of persons should be entered 
into. 

Every person borne upon the ship's papers as passenger or 
member of the crew should be personally seen by the boarding- 
officer or his assistant, and no excuse whatever should be taken 
for an absence from this muster. Take nothing for granted, 
and compel the master to explain any discrepancies between the 
lists and the actual number presenting themselves for examina- 
tion. The decision must now be reached whether the vessel 
goes free under the regulations or is to be detained in quaran- 
tine. If the former, the certificate of inspection is filled out, 
and the master notified that he is at liberty to proceed. If the 
latter, the vessel is directed to a suitable anchorage, and the 



MANAGEMENT OF A QUARANTINE STATION. 479 

yellow quarantine flag is hoisted at the foremast-head. Quaran- 
tine procedures proper now begin, and much depends on the 
nature of the disease quarantined against ; the nature and con- 
dition of the ship, whether light, in ballast, or loaded. If there 
are passengers on board, these are landed, bathed, and assigned 
to quarters in the barracks. The vessel is laid alongside of the 
wharf and the disinfecting processes prescribed by the regula- 
tions entered upon. 

The disinfection of iron and wooden vessels, while depend- 
ing on the same general principles, differs essentially in detail. 
This is illustrated in the following article on the " Disinfection 
of Wooden Vessels," by Surgeon H. R. Carter, published in the 
"Annual Report of the Marine-Hospital Service for 1892" : — 

Some Points in the Disinfection of Wooden Vessels 
for Yellow Fever. 

There are many points of difference to a quarantine officer between 
wooden sailing-vessels and steam-ships. The former lie longer in the 
ports of clearance ; the crews have communication with the shore ; there 
are more deserters, and consequently more men are shipped at these 
ports to take their places. All of these things affect a vessel's sanitary 
standing. 

The points, however, to which it is desired to call attention at 
present are (1) the treatment of ballast and (2) the disinfection of the 
hold, and both apply only to wooden sailing-vessels. 1 

TREATMENT OF BALLAST. 

This ballast is regarded differently by different boards of health, 
but by all as at least " suspicious." 

Florida regulations require the discharge of all ballast from infected 
ports before a vessel is allowed to enter. If the vessel is judged infected 
the ballast aboard must be removed at the refuge station to which she is 
sent, and new ballast not from an infected port substituted if any is 
needed. Disinfection of ballast is not recognized. 

Louisiana 2 allows it to be wet in situ with bichloride solution and 
to remain aboard during the fumigation ; then it is considered safe (1891). 

1 Save schooners and American-built square-rigged craft of small burden (brigantines 
and barkentines mainly), practically all sailing-vessels from yellow- fever ports come in ballast. 

3 The recommendation for a ballast lighter in the report of the Louisiana quarantine 
physician, 1890, shows that this method was not perfectly satisfactory to him. 



480 TEXT-BOOK OF HYGIENE. 

Savannah, which ascribes an epidemic to ballast, and Charleston, while 
requiring all ballast to be discharged at their own quarantine stations, 
yet allow " dipped " ballast from vessels that have been infected to be 
there discharged along with ballast from non-infected vessels, thus agree- 
ing to its harmlessness. A vessel of which the ballast may be infected 
is not allowed at either of these quarantine stations. 

Mobile and Mississippi ports allow " dipped " ballast to enter port, 
and, if need be, to remain aboard or to be discharged ashore. 

Is ballast often a source of infection ? From Havana, yes. From 
Brazilian ports, if of rock, no. It depends mainly on its material and 
whence procured. 

From Havana, Cienfuegos, and some other Cuban ports comes a 
fairly-good white stone ; a soft, crumbly, blue rock, containing talc and 
mixed with clay ; and what is called by masters and in the manifest 
" sand," but which contains so much old plaster, broken tiles, and bricks 
that " rubbish " would seem a better name for it. 

Twice this last and once (two cases) the blue-stone ballast is, be- 
lieved to have been the source of yellow fever in vessels at the Gulf 
Quarantine since 188*7. 

Rio, Santos, and the Brazilian ports south of Para send a gneiss 
or granite rock, not hard for its kind, but far better than the best Cuban 
ballast, and a loam due to its decomposition. This is also called " sand " 
in the manifests, and if dry may be taken for sand ; but it is really a loam, 
setting like cement when wetted. It is alkaline. Few vessels for Gulf 
or South Atlantic ports bring this " sand," as it is objected to by most 
quarantine officers, and the masters of vessels are suspicious of it them- 
selves, and when wet it makes a very dirty ship. 

From Rio both kinds come from high hills or mountains across the 
bay from the city, and the locality is considered to be a healthy one, but 
in 1889 I was informed that there was yellow fever among the quarry men 
as bad as elsewhere. 

Even with what is called rock ballast there is much small stuff and 
dust, especially under the hatches where it is taken in. This forms a 
compact mass with the larger stones under the hatches, there being fre- 
quently one hundred to one hundred and fifty tons of this close ballast 
in a vessel. The finest of it, however, is only granite sand, undecom- 
posed, and does not cohere with water. 1 

The writer is cognizant of only one case of yellow fever (British 
bark Chippewa, 1890), presumably due to Brazilian ballast, and this may 
well have been from another source. Nevertheless, in such rock ballast 

1 In 1889, when there was a very bad epidemic in Rio, the rock ballast from that port was 
nearly all small stuff. The government was using large rock on some public works, and the 
vessels took for ballast what was left on the lighters. 



MANAGEMENT OF A QUARANTINE STATION. 481 

at the Gulf Quarantine have been found rotten boards, articles of clothing, 
and (once) faecal matter, all at such a depth in the ballast that they must 
have come aboard at the port of departure (Rio, in these instances). 

Ballast from Colon is, for rock ballast, the worst possible, and, if 
infected, the best fitted to preserve infection. It is a friable, porous 
stone (coral?), filled with slimy mud, a fresh fracture staining water. 
Many cases of malarial (Chagres) fever were seen, certainly due to work- 
ing in this ballast, but no yellow fever has been ascribed to it the past 
four years. Probably little has been at Colon during this time. Cases 
of yellow fever were ascribed to ballast from Yera Cruz at the Gulf 
Quarantine (French ship Emil Postel, 1891). 

Regarding ballast from infected ports, then, as " suspicious " or 
" probably infected," it may be either (a) discharged or (b) disinfected. 
When possible, the former method is, of course, preferable on the ground 
of economy, the ballast being discharged by lighter or otherwise in about 
eight feet of water. Unfoitunatel}', most square-rigged sailing-vessels 
require ballast for their own safet} T , especially when going from outlying 
refuge stations to their loading ports ; and while ballast-logs may be sub- 
stituted in certain cases, }*et in manj^ others, the majority, they are inap- 
plicable. It is, therefore, in general, impossible to leave such a vessel 
empty of all ballast at a refuge station. Enough close-grained, picked 
rock (no small stuff or trash being allowed) to trim the vessel and render 
her safe may be disinfected and retained aboard. This disinfection is 
accomplished by dipping each piece in a solution (acid) of HgCl 2 , 1 to 
800 or 1000, as it is trimmed in the vessel's hold. The rock is immersed 
completely in the solution, and sta3~s wet with it some time, besides 
being continually wetted by the solution running down from those piled 
on it. Although some boards of health will not allow any ballast from 
an infected port or vessel to enter their jurisdiction, } T et it is believed 
that this dipped stone, hard and clean, is safe. Certainly, if washing a 
wooden, more or less splintered keelson with bichloride solution renders 
it safe to enter port with the vessel, the immersion of a granite rock in 
the same solution should give it, the rock, the same immunit}^. Indeed, 
the risk of conveying infection by picked rock, even without the disinfec- 
tion, must be exceedingly small. 

This is not the slow process it may seem, but is obviously slower 
than wetting the ballast with a hose as it lies, and a number of experi- 
ments were made at the Gulf Quarantine by wetting rock ballast with 
bichloride solution, opening the pile and testing individual stones for 
mercury. The solution was served through a 1^-inch hose by a strong 
steam-pump under full pressure, and observations were made aboard the 
ships Sardinian, Chrysolite, Prince Regent, and Curlew, and barks 

31 



482 TEXT-BOOK OF HYGIENE. 

President., Mabine, and others. In every case stones were found some 
part of which gave no reaction for mercury. As a rule, the parts in con- 
tact with other stones had been wet, while the parts not so in contact 
quite frequently did not show the reaction. 

A consequence of this is that where ballast is first fumigated and 
then wet down with bichloride solution there is some probability of the 
SO 2 reaching the parts of the stones not wet by the bichloride. This is 
less apt to take place if the fumigation follow the wetting down. 

It seemed as if the liquid followed certain paths in passing through 
the ballast, and after a certain amount of solution had been used no pro- 
portionate increase of wetting was observed by increasing the use of the 
solution. In these experiments the solution was used considerably in 
excess of what is usually used in wetting down ballast. 

Letters from masters of vessels which had had their ballast so 
treated elsewhere state that the ballast (rock and fine stuff) was, after the 
process, in good condition for handling except near the surface and next 
the keelson ; that no sand was carried into the bilge, and that " most of 
the fine stuff was as nice and dry as if the ballast had not been wet down." 
The same statements have been made verbally by several masters of 
vessels. 

It seems doubtful, then, if it be possible to certainly wet all of a 
vessel's rock ballast in situ by an amount of water short of submerging 
it, and that, if the ballast be infected, this method is less sure than that 
of dipping. 

Also, if ballast be thoroughly wetted, it is obvious that much sand 
must pass through the ceiling, stopping the limbers, fouling the pumps, 
and doing a certain amount of damage to the vessel, and requiring con- 
siderable work of the crew to correct it. 

Where this method was tried with sand it seemed to wet all of it ; at 
least every piece selected in the two vessels experimented on yielded the 
mercurial reaction. The sand was leveled so as to be as thin as possible, 
ditches dug across the hold, and then filled with the solution. After this 
soaked in, the ridges were turned into the ditches and the place where 
the ridges had been ditched, and these filled with solution of bichloride. 
To wet the sand thoroughly required from one-twentieth to one-twelfth 
of its weight of water. 

Colon stone is probably not disinfected by immersion in the solu- 
tion of bichloride unless the time of immersion be considerably prolonged 
— hours or da}-s ; nor was it ever judged safe to attempt to disinfect the 
rubbish ballast from Havana. 

Of course, the ballast is to be disinfected as far as possible in situ 
before discharging any, when it is believed that moving it will endanger 



MANAGEMENT OF A QUARANTINE STATION. 483 

the workers. But wet ballast is exceedingly disagreeable to handle and 
is injurious to the vessel, and, indeed, all work about a presumably 
infected vessel should be done by the acclimated quarantine crew. 

DISINFECTION OF HOLD. 

In 1888, 1889, and 1890 a series of rough experiments were made 
at the Gulf Quarantine to determine the penetrating power of S0 2 in suf- 
ficient amount to destroy animal life — ants and cockroaches. These were 
made in the holds of vessels undergoing disinfection, so as to be under 
the same conditions as those in which the gas was used in practice. 
These cannot be given in detail here, but they showed that a film of 
water (sea-water) from three to five inches thick presented such a barrier 
to the passage of the gas that in forty -eight hours it would not destroy 
insect life beyond it; that clothes soaked in sea-water thick enough to 
stay wet were equally impenetrable, while the same clothes dry allowed 
insects to be killed within them ; that rotten pine-wood, if reasonably 
dry, was penetrated four inches with the grain and less than two inches 
across the grain ; that this same wood soaked in sea-water was impervious 
for even one inch with the grain. 

Dr. Kinyoun informs me that a 10-per-cent. atmosphere of S0 2 (10- 
per-cent. volume) will destroy certain micro-organisms through six inches 
of rotten wood containing 16 per cent, of moisture, — I presume, with the 
grain. 

Now, in the hold of a vessel rotten wood is most apt to be found, if 
a^where, in the timbers in the ill-ventilated spaces between the skin and 
ceiling, at the ends of the deck beams, at the water-line near the stern, 
but in every case between the skin and ceiling. In spite of air-strakes 
and ventilators, the communication between these spaces and the open 
hold is very meagre, and is rendered still more so by the " stop waters " 
in all American vessels, — pieces fitted in between the timbers to keep the 
bilge-water from splashing up on the cargo when the vessel lays over in 
sailing. Obviously, then, if the hold of a vessel be infected the infection 
is most probably in the rotten wood, a favorite nidus in ill-ventilated 
spaces, and it is difficult to reach. 

It has been the habit to use a large amount of bichloride solution 
and to leave it in the vessel until she leaves quarantine, so as to splash 
about as she rolls and soak into her wood as thoroughly as possible. 
Nevertheless, it is obvious that no liquid can be depended on to reach 
and saturate all parts of the woodwork under the ceiling. A gaseous 
disinfectant is necessarj' if there be infection in these places, and the 
problem is to make it efficient. After opening every air-strake, — they 
are generally closed by battens on arrival in quarantine, — the main 



484 TEXT-BOOK OF HYGIENE. 

dependence for reaching these spaces must be by the cracks between the 
planks in the ceiling. Now, if the vessel be fumigated immediately after 
she is washed down with bichloride solution, and the washing is done as 
it should be, all of these cracks and all of the small interstices, where 
beams, etc., come together, are filled by films of this solution, through 
which this gas cannot pass, or passes with difficulty, and the places 
which most need disinfection cannot get it. 

This to me seems a more serious objection to using the bichloride 
solution before fumigating, in wooden vessels, than the fact that HgCI 2 
is partially converted into Hg 2 Cl 2 by the S0 2 , although this certainly 
occurs in pans holding bichloride in solution exposed in the hold of a 
vessel undergoing fumigation. 

Also, to enable the gas to diffuse itself through the cracks into 
these spaces in sufficient proportion to be efficient as a disinfectant, it is 
necessary to have it in the hold a considerable time. At the Gulf Quar- 
antine the hold was closed for forty-eight hours, and occasionally seven ty- 
two hours. This was done to allow for this diffusion, and not because it 
was believed that so long a contact of the gas with any infecting organ- 
isms was desirable. 

It seems right to state here that infection of the hold of a vessel, 
not meaning the ballast, is not common in vessels which have the houses 
on deck, and the contents of the hold, the ballast, is less commonly 
infected than the dunnage of the forecastle and cabin. 

To determine what part of a vessel is infected, beyond a mere prob- 
ability, is not usually possible ; indeed, to determine if a vessel be "prob- 
ably infected " is at times far from easy. 

Officially this is determined by the regulations of the quarantine 
station or port of entry, but a vessel may be officially judged infected 
and (rightly) submitted to disinfection when, in point of fact, the prob- 
ability of her. being infected is slight; and (for Middle Atlantic ports) 
the converse may occur. The fact of a vessel having had yellow fever 
aboard, especially if only at the port of clearance and not en route, may 
not be sufficient to class her as " probably infected." The circumstances 
of the attacks may be such as to show that they were contracted ashore, 
and that the sick men did not contaminate the vessel ; or there may be 
evidence to show that, although there was a source of infection aboard 
the vessel, it is no longer existing. 

For an instance of the first, among many instances, the American 
ship Fawne had six cases of yellow fever developing aboard her while at 
Rio in 1891, but in every case it developed in seamen who, the log 
showed, had returned from shore less than thirty-six hours before, and 
there had been no development of fever among a considerable number, 



TREATMENT OF YELLOW-FEVER VESSELS. 485 

twelve or fourteen, of unacclimated seamen living in the same forecastle 
and working over every part of the ship for about fifty daj T s since the 
last case aboard. From this vessel the sick were sent to hospital the 
first da}' of their sickness, with all of their loose dunnage with them. 
No supplies taken aboard, no men shipped, and only the master went 
ashore after the fever developed. This vessel was probably not infected 
at any time. 

As an illustration of the second, far less common than the first, 
the British ship Prince Frederick was infected at Rio in 1889. A 
number of cases — thirteen, I think — developed aboard her under con- 
ditions which showed that the}^ were contracted aboard, — i.e., in men 
who had had no recent communication ashore, and one case en route. 
She came up short-handed to Barbados, having en route destroyed some 
dunnage — that of the dead — and aired all of the rest, keeping it on lines 
in the sun all of every da}- when possible ; cleaned and ventilated the 
houses above decks, and ventilated the hold. The weather the whole 
time was bright, with light winds. At Barbados the crew was strength- 
ened by shipping new men, among them seven English lads, fresh young 
fellows from 16 to 21 } r ears old, who had never been south before, — the 
most perfect temoines for yellow fever, — yet no case developed among 
them, even when they cleaned ship. 

This vessel undoubtedly had a source of infection aboard, but was 
freed from it, probably, in consequence of the ventilation and other 
measures adopted. 

If there be dunnage packed away aboard which was infected when 
packed, no time-limit can be relied on for removing the infection, while 
persistent airing in bright weather will probably do so. Even washing 
in cold water, as sailors do, seems to be sufficient to disinfect fabrics 
from 3'ellow fever. 

Several cases are known where aired o^r washed clothing was 
handled with impunity by a number of unacclimated persons, from which 
} T ellow fever had been contracted by those who unpacked or washed it, and 
no case of infection from well-aired clothing has ever been known to the 
writer. Moisture seems necessary for the infection to keep its efficiency. 

It is not, of course, intended that airing, etc., should ever be relied 
on for the disinfection of fabrics ; only to show that some vessels may 
clear themselves of infection by this method and ventilation. 

TREATMENT OF YELLOW-FEVER VESSELS. 

It is fortunate that vessels from yellow-fever ports rarely 
have any considerable number of passengers on board, and that 



486 TEXT-BOOK OF HYGIENE. 

our efforts have therefore to be directed only to the cleansing of 
the ship, the care of those actually sick with the disease at the 
time of arrival, and the detention, under observation for a period 
of five days, of those exposed to the infection. The cleansing 
of the ship, whether of wood or iron, is specifically treated of 
in the regulations ; the disinfection of the cargo presents few 
difficulties, as the cargo is usually either sugar or coffee, gen- 
erally packed in bags, and admitting of thorough disinfection 
by the application of sulphur dioxide in the strength and for 
the time prescribed in the regulations. Several years ago the 
Louisiana State Board of Health issued a circular to shippers 
recommending that all cargoes of sugar and coffee be stowed 
with a shaft or tunnel under each hatchway, reaching from the 
upper tiers of the cargo to the keelson of the vessel. This shaft 
admits of the entrance of the sulphur-hose, and the gas, forced 
in under pressure, has free access to the envelopes of every 
package, which it penetrates to the depth of three-quarters of 
an inch or more, thus insuring thorough disinfection of the cargo 
without the necessity of breaking bulk, and at a minimum of 
time and expense. 

The sick should be at once carried to the infected hospital, 
if their condition permit it, and the remainder of the crew and 
passengers inspected twice daily until the time of danger is 
passed and the vessel is discharged from quarantine. 

Vessels from yellow-fever ports generally arrive at quar- 
antine stations either light or in ballast. The treatment of 
these vessels is so fully dealt with in the foregoing article of 
Surgeon Carter that further comment is unnecessary. 

TREATMENT OF CHOLERA VESSELS. 

In the event of the arrival of a ship actually infected with 
Asiatic cholera, or suspected of such infection, a much more 
difficult problem confronts the quarantine officer, for the condi- 
tions differ widely from those obtaining in the case of the yellow- 
fever ship. In a majority of cases the cholera ship carries a 



TREATMENT OF CHOLERA VESSELS. 487 

large number of passengers, a great majority of whom belong 
to the immigrant class, and the difficulty of handling these is 
largely increased by the carelessness of their personal habits, 
their ignorance and disregard of the first laws of personal 
hygiene, and the discomfort, crowding, and bad sanitary con- 
dition of their quarters on board ship. Here many sources of 
danger must be looked into, and it is almost certain that a 
disregard of any one of them will be followed by a terrible 
retribution in the shape of new outbreaks of the disease. 

The first thing to be done in the treatment of a cholera- 
infected ship is to remove her human freight, and this should 
be done as rapidly as is consistent with safety. The occupants 
of the compartment of the ship in which cholera has appeared 
should receive our first and most careful attention. Thev must 
be landed at once, bathed with all possible precaution and 
thoroughness, furnished with clean, sterile clothing, and isolated 
in the barracks and regarded as especially dangerous. Those 
actually sick with the disease should be at once carried to the 
contagions hospital, and those sick with any complaint whatever 
isolated in the suspect hospital pending the determination of the 
actual nature of their disease. 

The foregoing applies particularly to the steerage passen- 
gers. The question of the treatment of the cabin and saloon 
passengers is one that will call for all the tact and ingenuity of 
the quarantine officer, and even then he will be liable to savage 
criticism and censure through the friends of the cabin passen- 
gers detained. It must be remembered that these passengers 
are luxuriously lodged and catered for with every delicate atten- 
tion that ingenuity and long experience, sharpened by active 
competition, can suggest. On board ship they are most care- 
fully guarded from intrusion on the part of the steerage passen- 
gers, and, in fact, are as nearly on a separate ship as possible. 
Is it always necessary to subject these people to the inconveni- 
ences and possible hardships that are inseparable from a deten- 
tion in quarantine barracks'? The answer is that each case 



488 TEXT-BOOK OF HYGIENE. 

must be decided on its individual merits, and much will depend 
on the extent to which the ship seems infected, the seeming 
source of the infection, and the facilities which exist on board 
ship for maintaining a sharp line of demarkation between the 
steerage and saloon. 

If, on investigation, it seem that the choleraic outbreak is 
due to infected food smuggled on board by the emigrants, to 
infection probably brought aboard in the hand-baggage of the 
same class of passengers ; if, in fine, it would seem to be due 
to conditions limited to the steerage, it might seem to be the 
part of wisdom to leave the cabin passengers in their luxurious 
quarters while the processes of disinfection and detention were 
in progress. If, on the contrary, the infection seem to be due 
to a polluted ship's water-supply; if there have been any cases 
of diarrhoeal disease among the cabin passengers ; if the infec- 
tion seem to be distributed equally to the steerage and to the 
saloon, then all must be landed alike, and undergo barrack 
detention, at least, until the disinfection of the ship is thoroughly 
complete. 

The barracks for the cabin passengers must, of course, be 
of a different character from those provided for the steerage. 
They must be subdivided into small rooms, and, instead of 
bunks, must be furnished with comfortable cots, bedding, and 
simple, but neat and efficient, toilet facilities. A separate 
kitchen and table must be provided for this class of passengers, 
and the whole situation may be summed up by saying that the 
relative difference on shipboard should be preserved on shore 
during the detention in quarantine. 

SPECIAL MEASURES AGAINST CHOLERA. 

Other features of quarantine administration are well ex- 
pressed in the following extract from the editorial pages of the 
Philadelphia Medical Neivs of October 15, 1887, showing the 
measures necessary to extinguish an incipient epidemic of cholera 
and to prevent its spread. Such measures are as follow: — 



SPECIAL MEASURES AGAINST CHOLERA. 489 

(a) Speedy recognition and isolation of the sick ; their proper 
treatment; absolute and rapid destruction of the infectious agent of the 
disease, not only in the dejecta and vomit, but also in clothing, bedding, 
and in or upon whatever else it finds a resting-place. 

(b) The convalescents should remain isolated from the healthy as 
long as their stools possibly contain any of the infecting agent ; before 
mingling again with the well they should be immersed in a disinfecting 
bath, and afterward be clothed from the skin outward with perfectly- 
clean vestments, which cannot possibly contain any of the infectious 
material. 

(c) The dead should be well wrapped in cloth thoroughly saturated 
in a solution of corrosive sublimate (1 to 500), and, without delay, 
cortege, or lengthy ceremonial, buried near the place of death in a deep 
grave, remote as possible from water which may, under any circum- 
stances, be used for drinking, washing, culinary, or other domestic pur- 
poses. (Cremation, of course, is by far the safest way of disposing of 
cholera cadavers.) 

(d) Those handling the sick or the dead should be careful to dis- 
infect their hands and soiled clothing at once, and especialty before touch- 
ing articles of food, drinking, or culinary vessels. 

{e) In the case of maritime quarantine, the well should be disem- 
barked and placed under observation in quarters spacious enough to 
avoid crowding, and so well appointed and furnished that none will suffer 
real hardships. 

(/) Once having reached the station, those under observation 
should be separated in groups of not more than twelve to twenty-four, 
and the various groups should, under no pretext, intermingle. The quar- 
ters for each group should afford stationary lavatories and water-closets 
in perfect working condition, adequate to the needs of the individuals 
constituting the group, and supplied with proper means of disinfection. 
There should be a bed raised above the floor, proper coverings, and a 
chair for each member of the group, each person being required to use 
only his own bed. There should be a common table of sufficient size to 
seat around it all the members of the group, who should be served their 
meals from a central kitchen, and with table-furniture belonging to the 
station and cleaned b} T the common kitchen scullions. 

(g) Drinking-water, free from possible contamination and of the best 
quality, should be distributed in the quarters of each group as it is 
needed, and in such a manner that it is received in drinking-cups only. 
There should be no water-buckets or other large vessels in which hand- 
kerchiefs, small vestments, children's diapers, etc., can be washed by the 
members of any group. 



490 TEXT-BOOK OF HYGIENE. 

(h) Immediately after being separated into groups in their respect- 
ive quarters, every person under observation should be obliged to strip 
and get into a bath (a disinfecting one is preferable), and afterward be 
clothed with fresh, clean vestments from the skin outward. Ever}' article 
of clothing previously worn should be taken away and properly disin- 
fected. 

(i) Then all of the personal effects should be at once removed to a 
separate building, washed (if possible), and thoroughly disinfected, or, 
if necessar}', destroyed. After disinfection they should be temporarily 
returned to the members of groups, when occasion requires a further 
change of clothing. 

(k) Under no circumstances whatever should washing of clothing 
b}' those under observation be permitted. All used clothing should be 
first thoroughly disinfected (by boiling, when possible), and then should 
be cleansed, the disinfection and washing being done by a sufficiently 
trained and absolutely reliable corps of employes supplied with adequate 
appliances. 

(/) All those under observation should be mustered in their ow r n 
quarters, and be subjected to a close medical inspection, while on their 
feet, at least twice every clay, in order to discover and isolate, as soon 
as possible, new cases which may develop ; and, of course, the clothing 
and bedding of these new cases should be treated without delay in the 
manner already mentioned. In the mean time, a watch should be set 
over the water-closets for the purpose of discovering cases of diarrrhcea, 
and, when discovered, such cases should be temporarily separated from 
the rest. They should receive judicious medical attention at once, and 
precautions should be taken as if they were undoubted but mild cases of 
cholera. 

(m) The quarters should be kept thoroughly clean, and every sur- 
face upon which infectious material could possibly be deposited, includ- 
ing the floors, should be washed with a strong disinfectant twice daily, 
and oftener when necessary. Evacuations from the bowels should be 
passed into a strong disinfectant; the hopper of the- closet should 
be then flushed and finally drenched with a quantity of the same disin- 
fectant. 

(n) For the proper attention to the sick, there should be two or 
more competent and experienced physicians, assisted by a sufficient 
corps of intelligent and efficient nurses, with hours of duty so arranged 
that a physician, with a sufficient number of nurses, shall be in constant 
attendance in the wards of the hospital. 

(o) For the prompt recognition and separation of new cases, their 
temporary medical attention, the proper treatment of discovered cases 



REGULATIONS FOR CHOLERA CAMP. 491 

of diarrhoea or cholerine and of other maladies, and the immediate cor- 
rection of every insanitary practice or condition by constant, vigilant, 
and intelligent supervision, there should be at least two or more compe- 
tent and experienced physicians, with hours of service so arranged that 
a physician is on duty night and day among those under observation ; 
and he should have, subject to his orders at any and every moment, a 
sufficient and efficient corps of nurses and laborers to carry out properly 
and promptly his directions. 

(p) In order to prevent the intermingling of the various groups, to 
enforce obedience and order, and to make it absolutely impossible for the 
quarantined and their personal effects to have any communication with 
the exterior, a well-organized and sufficiently large police corps should 
patrol the borders of the stations and the buildings day and night. 

(q) Any group among whom there have developed no new cases of 
cholera or of choleraic diarrhoea, during the preceding eight or ten da}'s, 
may be regarded as harmless, and allowed to leave quarantine after each 
one is finally immersed in a disinfecting bath and re-clothed with clean 
garments from the skin outward, the garments removed being destroj^ed 
or thoroughly disinfected and cleansed, as already indicated. 

As yet no reference has been made to the crew, ship, and cargo. 
What has been said of the treatment of those under observation applies 
to every one of the ship's inhabitants. The observation, isolation, and 
cleansing of the crew and their effects could safely be performed aboard 
ship if necessary. The ship should be thoroughly cleansed and disin- 
fected, particular attention being given to the quarters of the emigrants 
and crew. 

The following general regulations were promulgated for 
the government of camps and barracks for the detention of 
cholera suspects during the summer of 1892: — 

REGULATIONS FOR CHOLERA CAMP. 

(Prepared in the Marine-Hospital Bureau.) 

The surgeon in command of the quarantine camp to have 
absolute authority over the police and sanitary regulations of 
the camp, and to see that they are obeyed. 

Camp to be divided into two divisions, — detention and 
hospital. Former for housing of suspected cases and well per- 
sons from infected localities and the latter for treatment of sick. 



492 TEXT-BOOK OF HYGIENE. 

DETENTION CAMP. 

1. Persons destined for this camp to be assigned to specific 
quarters in tents. First to be subjected to disinfecting bath, 
and clothed afterward with fresh vestments. Not to leave this 
camp except by permission or order of surgeon in command. 

2. Persons in detention camp to be inspected twice daily 
or oftener by medical officer or assistant, while standing, to 
ascertain any new cases which may develop. 

3. New cases of cholera in detention camp to be immedi- 
ately transferred to hospital camp for treatment, and all their 
effects disinfected, as well as the tent in which they may 
occur. 

4. Guards to patrol detention camp night and day, to pre- 
vent intercourse between the two divisions of the camp. 

5. Water-supply for entire camp to be boiled for drinking. 
To be dealt out to each person in cups or glasses for potable 
purposes. May be acidulated with diluted hydrochloric acid 
under supervision of a medical officer. 

6. If there be room, the detention camp to be segregated 
into divisions of not more than twenty persons. No intercom- 
munication should be permitted between the groups. 

7. All clothing removed from persons entering detention 
camp to be subjected to steam heat (unmixed with air), not less 
than 100° C. (212° F.), for one-half hour, or boiling for one 
hour. Leather and rubber goods to be immersed in 3-per-cent. 
carbolic-acid solution until thoroughly saturated. 

8. The washing of clothing not to be permitted by the 
detained persons under any pretext. After above disinfection, 
all laundry- work to be then done by the force of employes. 
The clothing of detained suspects should be kept in separate 
building after disinfection, and re-issued as required for 
change. 

9. Cleanliness and disinfection of quarters and person to 
be enjoined and enforced daily. Disinfectants to be used where 
there is any possibility of infection. 



HOSPITAL CAMP. 493 

10. At the expiration of five days, if no case of cholera 
or choleraic diarrhoea has developed in a given group segre- 
gated as above, those composing the group may be discharged, 
after a final disinfection of person and clothing. 

11. All water-closets, urinals, privies, or troughs should be 
provided with latrines similar to those of the cholera camp, 
and means should be provided for their thorough disinfection 
before their contents are discharged into pits of unslacked 
lime. 

12. Food issued shall be simple, thoroughly cooked, and 
served at stated hours. No fruit permitted. 

HOSPITAL CAMP. 

1. Day sick-calls at 8 a.m. and 4 p.m.; oftener, if necessary. 
Night call, 12 p.m., by night physician; oftener, if circum- 
stances require. 

2. There shall be one nurse for every hospital tent, who 
shall be on duty in six-hour watches. 

Night nurses according to circumstances. Female nurses 
for cases occurring in that sex. 

Nurses should be instructed in the necessity of personal 
hygiene and the sources of infection. 

3. Vomited matter and stools to be received into earthen 
vessels, and at once disinfected with 3-per-cent. solution of car- 
bolic acid or 1 to 500 HgCl 2 combined with 2 parts of HC1 to 
each part of HgCl 2 ; then thrown into a pit of unslacked lime, 
or discharged into the sea. 

4. All soiled linen or clothing that cannot be disinfected to 
be immediately destroyed by burning. 

5. When death occurs, body to be immediately buried, 
swathed in sheets saturated with 1 to 500 HgCl 2 . Place of 
interment to be selected to avoid contamination of w T ater-supply. 

6. No persons having personal contact with the sick or 
dead shall leave the hospital camp without practicing disinfec- 
tion, as specified above. 



494 TEXT-BOOK OF HYGIENE. 

DANGER FROM FLIES IN QUARANTINE. 

In this article it has been suggested that all dejecta and 
vomited matters of cholera patients be received into vessels con- 
taining an efficient germicidal solution ; and this is not only for 
the reason that the said dejecta and vomited matters may infect 
any one who comes into inadvertent contact with them, but has 
an important bearing on the health of those who are resident 
in the neighborhood of the quarantine station. It has been 
abundantly proved that the ordinary house-fly is capable of con- 
veying in its intestinal tract, for a considerable length of time, 
living and active cholera spirilla. Knowing how constantly 
flies deposit their ordure on articles of food, it can easily be seen 
how great a menace to public health would be engendered by 
allowing stools containing the bacilli to remain without instant 
disinfection. The safer plan is, therefore, to not trust to subse- 
quent disinfection, which might be overlooked in the press of 
other matters, but to receive the dejecta into the germicidal 
solution so that no time will be lost and no chances of infection 
may remain. 

The National Quarantine Service. 

The national quarantine stations, eleven in number, are 
established at points of danger where either local quarantine is 
defective or where, by reason of peculiar advantage in location, 
protection is afforded to several States by one station. These 
stations are as follow: — 

Delaware Breakwater Quarantine Station, Lewes, Del. ; 
Reedy Island Quarantine Station, Delaware River; Cape 
Charles Quarantine Station, Fisherman's Island, Va, ; South 
Atlantic Quarantine Station, Blackboard Island, Sapelo Sound, 
Georgia ; Brunswick Quarantine Station, Brunswick, Ga. ; 
Key West Quarantine Station, Tortugas Islands, Fla. ; Gulf 
Quarantine Station. Ship Island, Miss. ; San Diego Quarantine 
Station, San Diego, California; San Francisco Quarantine Sta- 
tion, Angel Island, San Francisco Bay, California ; and Port 



THE NATIONAL QUARANTINE SERVICE. 495 

Townsend Quarantine Station, Port Townsend, Washington. 
A station has been authorized by Congress and will be erected 
at Southport, N. C. 

DESCRIPTION OF THE NATIONAL QUARANTINE STATIONS ON 
DELAWARE BAY AND RIVER. 

It ma}' prove of interest to briefly describe a national 
quarantine station,, and no better example can be found than 
the stations at Delaware Breakwater and at Reedy Island, 
Delaware River. These stations, while in a measure separate 
and distinct, are intended to work in connection with each 
other and to afford complete protection against the importation 
of contagious and infectious disease through the medium of the 
commerce which seeks the port of Philadelphia and the ports 
of entry on Delaware Bay, and situated in the States of Dela- 
ware, New Jersey, and Pennsylvania. At the station at 
Delaware Breakwater, which is situated at the mouth of Dela- 
ware Bay and immediately upon the point formed by Cape 
Henlopen, is the reservation, forty acres in extent, and sur- 
rounded by a substantial picket-fence ten feet in height. 
Within this enclosure is located the quarantine plant proper, 
consisting of commodious hospitals for contagious and non- 
contagious diseases, and barracks for the accommodation of 
one thousand suspects, fitted with bunks and provided with 
bedding and a full supply of clothing for both males and 
females. In connection with these barracks are a large kitchen, 
fully equipped with steam cooking-apparatus of the most im- 
proved description and a commodious mess-hall. There has 
been also provided a building containing a boiler for operating 
the pumps, a bath-house, and laundry, which latter is equipped 
with appliances for washing all soiled clothing and for subject- 
ing them to the boiling process. In this building there is also 
located a steam disinfecting chamber of the most modern and 
improved type, and adjoining this building is a bath-house 
fitted with twenty shower- and two tub- baths, all provided with 



496 TEXT-BOOK OF HYGIENE. 

hot and cold water. An artesian well has been sunk, capable 
of supplying twenty thousand gallons of water per day, and 
this water is raised by a powerful pump to elevated tanks, and 
from these distributed to the barracks, kitchens, hospitals, 
laundry, and bath-house. 

Latrines are provided and furnished with iron containers 
holding a strong disinfecting solution, and provision is made for 
emptying these containers into a sewer, which, in turn, empties 
into a sewer common to the bath-house and laundry, which 
discharges into the sea. The danger of soil contamination by 
alvine discharges is reduced to a minimum, and the water-supply 
likewise protected. Outside of the fence is a large brick house, 
which furnishes executive and administrative offices and quarters 
for the medical officers on duty at the station. In front of the 
executive building is a lofty flag-staff, which affords the means 
for communicating by signals with vessels in quarantine and 
arriving in the offing. 

Within a few hundred yards of the reservation is a long 
iron pier, which affords ample facilities for the landing of pas- 
sengers. 

Situated fifty-five miles above the Breakwater, and forty- 
five miles from Philadelphia, is the Reedy Island Quaran- 
tine Station, on and near the island of that name. Upon the 
island itself are situated the residence of the medical officer, 
quarters for employes, and a cottage hospital. A boat-house is 
connected with the island by a gangway. The quarantine plant 
proper is located on a pier situated on the edge of the channel, 
and in thirty feet of water. The pier is two hundred feet in 
length, and presents a frontage of nearly four hundred feet, 
owing to the placing of an ice-break above and below the 
pier. This affords room for the accommodation of the largest 
vessels, and upon the wharf is situated the disinfecting plant, 
consisting of two steam chambers ; a sulphur-furnace, fan 
and engine for driving the same; tanks for disinfecting solu- 
tions and a pump and hose for their distribution ; a fire-pump, 



AIDS TO NATIONAL QUARANTINE. 497 

and tanks for the storage of water for fire and steaming 
purposes. 

There are no barracks at this station, it being the plan that 
the vessel shall receive quarantine treatment at this point, and 
that the passengers shall undergo their detention in the barracks 
at the Breakwater station. 

Another national station which deserves special notice from 
its peculiarities is the quarantine vessel Jam , which can 

be considered a floating quarantine station. The town 

was turned over to the U. S. Marine-Hospital Service by the 
Navy Department for quarantine use. She is one of the old- 
fashioned sailing-vessels of the navy, is very strongly and 
solidly constructed, and is one hundred and sixty-six feet long, 
thirty-six feet beam, and has a displacement of eight hundred 
and eighty-eight tons. She has been fitted for her present use 
by being housed in. and there have been placed on board a 
steam disinfecting chamber, a sulphur-furnace, tank for bichlo- 
ride solution, and bath-rooms. In addition to these, she has 
been fitted as a place of detention for two hundred and fifty to 
three hundred immigrants, and is in all re a complete 

quarantine station, and capable of doing valuable service in 
smooth water. 

AIDS TO NATIONAL QUARANTINE. 

In aid of the national quarantines, sanitary inspectors are 
appointed by the Marine-Hospital Service at special points oi 
danger, either in the United v :e:es or abroad. Through the 
State Department consular notification from foreign ports is 
received regularly by mail. or. in emergency, by cable, and the 
information thus received, and that received also from home 
ports, is communicated, by the Marine-Hospital Bureau, to all 
quarantine authorities and others, by means of a weekly publi- 
cation known as the "Abstract of Sanitary Report- " 

An important source of information concerning the move- 
ments of vessels in every portion of the world is the •• Maritime 



498 TEXT-BOOK OF HYGIENE. 

Register," published in New York. The United States Col- 
lectors of Customs are efficient aids, having, by law, the power 
of search and detention of vessels, and having exceptional 
knowledge of the sanitary condition of the shipping at their 
respective ports. The Revenue-Cutter Service, a national coast 
patrol, gives frequent and efficient aid ; the Light-house Estab- 
lishment and Coast Survey render valuable assistance in locating 
and buoying the anchorages, and the Life-Saving Service, with 
its constant patrol of the coast, guards against the entry of a 
vessel at an unusual point. The surf-men are required to rake 
together and destroy dunnage and other material likely to be 
infected that have been thrown overboard and washed ashore 
from infected vessels. Finally, the Marine-Hospital Service, 
having, besides the quarantines, the care of the sick of the 
merchant vessels of the United States, with one hundred and 
twenty-six physicians stationed at the larger and many of the 
smaller ports, is ready at a moment's notice to extend in- 
definitely its quarantine service. 

National Inspection of all Quarantines. 

The Act of Congress approved February 15 1893, while 
contemplating that State and local quarantines shall not be dis- 
turbed in the exercise of their functions, provided said quar- 
antines are administered in accordance with the law and the 
regulations made thereunder, further provides that the rules 
and regulations of local quarantines shall be examined by the 
Surgeon-General of the Marine-Hospital Service, and also that 
such additional rules and regulations as may be deemed neces- 
sary shall be made by the Secretary of the Treasury, and shall 
be enforced by the State or local quarantine authorities. If tire 
latter refuse, or are unable to enforce them, the law further 
provides that the President of the United States shall detail or 
appoint an officer for this purpose. To carry out the intent of 
this law all the quarantines of the United States, national, State, 
and local, are inspected periodically by an officer of the Marine- 



NATIONAL INSPECTION OF ALL QUARANTINES. 499 

Hospital Service. Following are the instructions prepared for 
the inspecting officers: — 

Instructions to Medical Officers of the Marine-Hospital Service 
Detailed to Make Inspections of State and Local Quarantines. 

treasury regulations. 

***** **** 

In the performance of the duties imposed upon him by the act of 
February 15, 1893, the Supervising Surgeon-General of the Marine- 
Hospital Service shall, from time to time, personally or through a duly- 
detailed officer of the Marine-Hospital Service, inspect the maritime 
quarantines of the United States, State and local, as well as national, for 
the purpose of ascertaining whether the quarantine regulations pre- 
scribed by the Secretary of the Treasury have been, or are being, com- 
plied with. The Supervising Surgeon-General, or the officer detailed b} r 
him as inspector, shall, at his discretion, visit any incoming vessel, or any 
vessel detained in quarantine, and all portions of the quarantine estab- 
lishment for the above-named purpose, and with a view to certifjing, if 
need be, that the regulations have been, or are being, enforced. — J. G. 
Carlisle, Secretary. 

GENERAL INSTRUCTIONS. 

A. Your inspections will include all ports within your district 
where vessels are allowed to enter and discharge cargo, and ports which 
may be used as ports of call. 

B. A separate report will be made of each station visited. 

C. Visit every part of the quarantine establishment, and take 
necessary precautions to prevent the conveyance of contagious or infec- 
tious disease through the medium of 3-0 ur own person. 

D. Visit the custom-house for the purpose of ascertaining whether 
the regulations with regard to bills of health and quarantine certificates 
are being observed ; also, the immigration station for any pertinent 
information. 

E. Reports of a statistical character and descriptive of the quar- 
antine, called for herein, need be made but once in every six months, 
namely, on the date nearest the 1st of January and the date nearest the 
1st of July ; but any changes that have been made since the last general 
report should be immediately recorded. 

In making your report you will follow the special instructions in 
their order, referring to each by number. 



500 TEXT-BOOK OF HYGIENE. 

SPECIAL INSTRUCTIONS. 

1. Describe the quarantine station, location, buildings, anchorages, 
etc. Give limits of anchorage for non-infected and for infected vessels ; 
facilities for inspection of vessels; apparatus for disinfection of vessels 
and of baggage ; facilities for removal and treatment of the sick, and for 
the removal and detention of suspects ; mail and telegraph facilities, etc. 

2. Give personnel of the station or port ; name of the quarantine 
officer or officers ; post-office address ; total number of officers and 
subordinates, etc. 

3. Transmit copies of the laws under which the local quarantine is 
maintained, and copies of the quarantine regulations ; also describe the 
quarantine customs of the port as they are carried out. 

Note. — There are sometimes slight, but possibly important, variations from the 
letter of the local regulations in the administration of quarantine. Also, local regula- 
tions generally allow a wide latitude to the quarantine officer, and how this latitude is 
used — i.e., how the quarantine officer interprets the spirit of the regulations — is very 
important. 

4. State what quarantine procedures, either under printed regula- 
tions or by custom, are enforced at the port, in addition to the require- 
ments of the Treasury Department. 

It should also be stated whether there is undue or unnecessary 
detention or disinfection of vessels. 

5. State whether the inspection is maintained throughout the year 
or for what period, and what treatment of vessels is enforced during the 
entire year. 

Note. — Many ports on the South Atlantic coast (e.g., Charleston, Savannah, and 
Fernandina) require certain ballasts to be discharged in quarantine without regard to 
season. 

6. Are vessels from other United States ports inspected ? 

7. Describe quarantine procedures in the inspection of vessels, 
and, if infected, the treatment. Give time in quarantine (a) between 
arrival and commencement of disinfection, (b) time occupied by disin- 
fection, and (c) time after completion of disinfection of vessels until 
discharge. 

Note. — Quick or slow handling of a vessel is of more importance commercially 
than the question of fees. The time lost is the vessel's heaviest expense, generally. 

8. What communication is held with vessels in quarantine (and, 
before quarantine, by pilots, etc.), and how regulated? Is there any 
intercommunication allowed among vessels in quarantine? 

9. State wh.it will be done with a vessel infected with cholera; 
second, a vessel infected with 3 T ellow fever; third, a vessel infected with 
small-pox (said vessels carrying or not carrying immigrants), and what 



THE SANITARY CORDON. 501 

conditions are regarded as giving evidence of the vessel's infection in 
each case. 

10. State whether records are kept, at the station, of the cases of 
disease that have occurred during the vo3'age, on arrival, and during 
detention. 

11. Transmit schedule of quarantine fees, and give other fees and 
expenses necessarily and usually attendant on quarantine, as tonnage, 
ballast, wharfage charges, etc. 

12. Make a statement showing the number of vessels arriving at 
the port during the preceding calendar year, by months, (a) from 
foreign ports; (6) from foreign ports in yellow-fever latitudes via do- 
mestic ports; (c) from domestic ports. Show, also, the character of the 
commerce carried on by the port, — i.e., from what countries chiefly the 
vessels come, and whether in cargo, ballast, or empty. 

13. State results of } T our visit to (a) the Custom-house; (b) the 
Immigration Bureau. 

14. State whether, in your opinion, the quarantine facilities are 
sufficient to care for the shipping entering the port. 

15. Name the quarantine regulations of the Treasuiy Department 
which are not properly enforced, and state specifically whether the regu- 
lations regarding inspection and disinfection, and particularly the period 
of observation after disinfection, of vessels are observed. 

16. Mention an} T facts which, in your opinion, should be known to 
the Department, bearing directly or indirectly upon the quarantine 
service, and make such recommendations as seem proper. — Walter 
Wyman, Supervising Surgeon- General M.-H. S. 

Note. — Report to be written on legal-cap paper (on one 6ide only), signed, and 
inclosed in this blank as a cover. 

Inland Quarantine. 
Under Inland Quarantine will be described The Sanitary 
Cordon, Camps of Probation, Railroad Quarantine, Disinfection 
Stations, and Inspection Service. 

THE SANITARY CORDON. 

This consists of a line of guards, military or civil, thrown 
around a district or locality, either to protect the same from the 
surrounding country when infected, or to protect the surround- 
ing country from the infected district or locality. When a 
given locality is infected, and the adjacent territory is regarded 



502 TEXT-BOOK OF HYGIENE. 

as suspicious, it may be necessary to establish a double cordon, 
the first one embracing the whole suspected territory at its 
outer edge, the second investing more closely the well-defined 
infected locality. After the expiration of a sufficient time to 
prove that the area between the cordons is not infected, or has 
been cleared of infection, the first cordon may be removed. 
Hospitals and camps of probation may be necessary adjuncts to 
the cordon. The most noted example of the sanitary cordon is 
found in the history of the plague-epidemic in Russia in 1878. 
A colony on the river Volga, called Wetljankaja, with a popu- 
lation of 1700 inhabitants, became infected with the Oriental 
plague, which extended to the neighboring villages. A military 
cordon was made to embrace all the infected district. The in- 
habitants of the focus of infection, Wetljankaja, were removed, 
property appraised for re-imbur semen t by the government, and 
the village burned. An additional cordon was thrown around 
Zarizin, a neighboring commercial city of importance and ter- 
minus of the Russian railway system. The cordons were main- 
tained several months, and the plague was stamped out. (See 
Abstract Sanitary Reports, vol. i [Bulletin's], page 78.) The 
sanitary cordon is the customary method of preventing the 
spread of epidemic disease in the eastern countries. 

In the United States, when yellow fever prevailed in Pen- 
sacola, in 1882, to the extent of 2200 cases, the navy-yard 
reservation, whose boundary-line is within two miles of the 
city limit, and with a population of about 1500, was successfully 
guarded by means of a cordon and non-intercourse. 

The following year, 1883, the navy-yard itself was infected, 
and a cordon was thrown around it to protect the city of Pen- 
sacola, and was maintained for a period of sixty days. This 
cordon was under the management of the Surgeon-General of 
the Marine-Hospital Service, aid having been requested of the 
national government. The Collector of Customs of Pensacola 
was made the agent to execute the orders of the Marine-Hos- 
pital Bureau, and to the President of the local Board of Health 



THE SANITARY CORDON. 503 

was intrusted the immediate command of the line and guards. 
The cordon entirely surrounded the land-boundary of the naval 
reservation. Its line was lour miles in length, one mile of it 
through a dense thicket, and was marked by blazed trees and 
flags. Forty men were employed as guards, an equal number 
being selected from each of the two political parties. Two 
captains were appointed, and were obliged to supervise the line 
night and day. 

The sentinel posts were furnished with tents, and two guards 
were allotted to each post, taking alternate watches of four 
hours each. A detention or probation camp was established 
and placed in charge of a physician, where persons wishing to 
leave the reservation were obliged to pass a probationary period 
of twenty days. Not more than half a dozen persons were 
received in this camp. The government expended about 
$20,000 in these restrictive measures, which were entirely suc- 
cessful. Not one person got through the cordon line. The 
success was due largely to the thorough discipline maintained 
by the Collector and the President of the Board of Health. 

Yell oic- Fever Cordon in Texas. — In 1882. yellow fever 
prevailing in Mexico, along the Rio Grande, and in Browns- 
ville, Texas, a sanitary cordon was established by the Surgeon- 
General of the Marine-Hospital Service, on request of the 
Governor of the State, extending along the line of the railroad 
from Corpus Christi, on the Gulf of Mexico, inland to Laredo, 
on the Rio Grande. This line was one hundred and eighty 
miles northeast of Brownsville, the triangular territory thus 
hemmed in by the cordon on one side, the Rio Grande on 
another, and the Gulf on the third, being all suspected terri- 
tory, although the fever prevailed in only one corner of it, — 
viz., in Brownsville. All persons were detained at least ten 
days at the cordon before being allowed to pass northward, — a 
period of probation to insure that no one having the disease 
should carry it farther north. As soon as practicable another 
cordon was established much nearer to Brownsville, only thirty 



504 TEXT-BOOK OF HYGIENE. 

miles from it, the line extending from the mouth of the Sol 
Colorado, on the Gulf of Mexico, to Santa Maria, on the Rio 
Grande. After a time sufficient to prove that no more fever 
prevailed between the two cordons, the first one was removed. 
Within the second line, where the fever prevailed, chiefly in 
Brownsville, a hospital was established and dispensaries opened 
for the gratuitous treatment of all applicants. 

Upon the Mexican side of the Rio Grande the fever con- 
tinued to spread northwardly, and, in order to oppose it, still 
another cordon had to be established on the American side of 
the river, extending from Santa Maria on the south to Laredo 
on the north, a distance of five hundred miles. Three hundred 
guards, well mounted (Texan cow-boys), were employed in this 
cordon, and, while the disease was being stamped out in 
Brownsville, any further importation from Mexico was thus 
prevented. In Mexico the fever continued to spread until the 
authorities finally adopted measures similar to the above. 

The epidemic of yellow fever in Brunswick, Ga., in 1893, 
gave rise to the necessity of establishing a sanitary cordon to 
protect the surrounding country from the danger incident to the 
panic-engendered flight of the inhabitants of that town. On 
account of the peculiar situation of Brunswick the difficulties 
to be met were very great. Not only were numerous roads to 
be guarded, but three water-passages from the city into the 
surrounding country had also to be watched. The cordon, 
therefore, partook of the nature of both a land and water 
patrol, and the difficulties were successfully overcome, and 
no well-authenticated instances of escape through the lines 
were established. 

Much violent language has been used concerning the 
hardships imposed by the sanitary cordon, but in the presence 
of an epidemic the authorities who are responsible need to pay 
more heed to the efficiency of the cordon than to individual 
complaints. It should be borne in mind that the sanitary 
cordon is not intended to bottle up all the people who are 



CAMPS OF PROBATION. 505 

caught within an infected district. On the contrary, it is 
intended as a means of exit to those who will not carry with 
them contagious disease to the people beyond. 

The cordon, then, imposes simply a period of detention 
corresponding to the incubative period of the prevailing disease. 
Ample preparation must be made for housing and feeding, in 
camps or other quarters, persons awaiting the expiration of the 
detention period ; and hospitals must be provided for the treat- 
ment of those who develop sickness. Provision must also be 
made for the disinfection of suspected baggage. 

CAMPS OF PROBATION. 

Camps of probation or detention should be established with 
all the precision of arrangement and regard for site, water, and 
drainage that pertain to a military camp. Every effort should 
be made to make the camp as comfortable and cheerful as pos- 
sible, and to this latter end amusements and entertainments 
such as might be suggested by the campers themselves should 
be encouraged. Every necessity in the matter of food, bedding, 
and the ordinary comforts of life should be anticipated, to pre- 
vent any just cause of complaint. Such a natural division of 
the inhabitants should be made as seems desirable at the time, 
those of equal intelligence and refinement naturally seeking 
each other's company. The greatest concern is to prevent the 
camp itself from becoming infected. To this end no baggage 
should be allowed within the camp-boundary without previous 
disinfection ; and every refugee should be examined by a phy- 
sician before being admitted to the camp. No one should be 
received who does not intend to proceed to an uninfected locality 
after his probation. In other words, a camp of probation should 
not be used as one of refuge. 

The camp must be surrounded by guards to prevent egress 
or ingress, excepting through the established portal. At least 
twice or three times in the twenty-four hours all refugees should 
be inspected in their quarters, and any case of sickness at once 



506 TEXT-BOOK OF HYGIENE. 

be isolated and watched until the diagnosis is certain. If the 
case is one of the prevailing disease, the patient must be re- 
moved immediately to the hospital, which should be at a safe 
distance, half a mile or more, from the camp. Before leaving 
the camp, each refugee's clothing should be fumigated, and he 
should be given a certificate that he has passed the required 
period of probation. A clear distinction must be made between 
camps of probation and camps of refuge. Camps of refuge are 
simply residence camps established to receive the population of 
an infected community when it has been determined to depopu- 
late the infected district. 

Depopulation of a house, a block, a district, or a whole 
city, if possible, the people moving into camps, is now recog- 
nized as a valuable means of controlling an epidemic; and 
there may be either camps of probation or simply camps of 
refuge, or both, according to the requirements of the situation. 
Camps of refuge, in connection with depopulation, were sug- 
gested by the late Surgeon-General Woodworth, in 1878, and 
the measure was practically carried out at Memphis, in 1879, 
by the establishment of Camp Mitchell. " But the establish- 
ment of a camp to which persons from infected points could go, 
be kept under observation a sufficient length of time to demon- 
strate they were not infected, have their baggage disinfected, 
and be given 'free pratique,' is apparently a new departure in 
inland quarantine." 

Camp Perry, Fla. — Such was Camp Perry, Florida, de- 
scribed by the surgeon in charge, W. H. H. Hutton, in the 
Marine-Hospital Service Report for 1889. The site was admira- 
bly chosen by Passed Assistant Surgeon John Guiteras, upon a 
bluff on the south side of St. Mary's River, the dividing line 
between Florida and Georgia, about forty miles north of Jack- 
sonville, Fla., which city was in the throes of a yellow-fever 
epidemic. The camp was opened August 20, 1888. It con- 
sisted, in its completed stage, first, of 50 wooden cottages built 
elsewhere and transported on cars, Their dimensions were 12 



CAMPS OF PROBATION. 507 

feet by 10, and 10 feet in height, constructed of plain lumber, 
with cracks battened, and windows on each side with swinging 
shutters. Each held four cots, chairs, and toilet-stand, while 
unused clothing was neatly arranged on the rafters above. 
Besides the 50 cottages there were a quartermaster and guard- 
house, commissary building, dining-room and kitchen, and 
laundry, built of rough lumber ; 2 Ducker portable barracks, 
each 18 by 35 feet, provided with 12 beds each, and 350 
tents, used principally by the single men, the employes and 
guards, and the colored refugees. So far as known, this is 
the first camp of the kind ever established ; at least, in the 
United States. The cottages were arranged in a quadrangle 
around a parade-ground two acres in extent, and the tents were 
arranged in streets and alleys in the rear of the cottages. The 
accommodations were sufficient for 600 people, and extra tents 
were on hand so that, if required, 1000 persons could have been 
provided for, or 3000 per month, allowing for only ten days' 
detention of each person. Two hundred hospital tents will 
accommodate 1200 people comfortably, according to Surgeon 
Hutton, who states that the small A- tents are unsuited for 
women and children, but will answer for men or boys. Wire- 
mattress cots should be provided. The marine-hospital officer 
at Savannah Ga., was the purchasing agent for the camp, and 
promptly forwarded all subsistence supplies on requisition by 
mail or telegraph. 

Discipline of the Camp. — On arrival of a train, each pas- 
senger was personally examined by a physician, his health- 
certificate scrutinized, and he was made to await the examination 
of others. Hand-bags, clothing, and loose wearing-apparel 
were left in the baggage-car for disinfection. The refugees were 
then marched to the quartermaster's room for registration and 
assignment to quarters. On first arrival they were placed in the 
southern part of the camp, and in two days, there being no 
sickness, were moved forward several cabins, and this progres- 
sion was repeated until the time for discharge. 



508 



TEXT-BOOK OF HYGIENE. 



Twelve guards were employed, under the command of a 
captain, and were divided into squads of four each. The 
schedule was so arranged that each guard was on duty two 
hours and off duty four. 

A bugler announced the several calls, as follow : — 



5.30 a.m., . 


. Reveille. 


6.00 A.M., . 


. Breakfast, employe's. 


7.00 A.M., . 


. Breakfast, guests. 


9.00 A.M., . 


. Surgeon's call and inspection. 


2.00 m., . 


. Dinner, employe's. 


1.20 p.m., . 


. Dinner, guests. 


4.30 p.m., . 


. Surgeon's call and inspection 


5.30 p.m., . 


' . Supper, guests. 


6.00 p.m., . 


. Supper, employes. 


6.30 p.m., . 


. Retreat and change of guard. 


9.00 p.m., . 


■ Retiring taps. 



The yellow-fever hospital camp, under the special charge 
of Dr. Faget, was located one-half mile from the probation 
camp. It consisted of 2 frame buildings, 2 hospital and 12 
smaller tents, arranged in a double-crescent shape, the avenue 
in the middle presenting an attractive appearance. 

Of the 12 small tents, 4 were for nurses, 3 for employes, 
2 for convalescents, and 1 each for drug-store, storage- and 
dead- house. One of the hospital tents was used as a dining- 
room for employes, convalescents, and parents of the sick. 

The hospital was established September 3, 1888, and be- 
tween that date and November 24th 35 cases of yellow fever 
were admitted and treated, 3 died, and 32 were discharged. 
Twelve hundred and eleven refugees were received into Camp 
Perry, nearly all of whom were from the infected district of 
Jacksonville. 

Thirty-five cases of yellow fever were caught by the ten 
days' detention, but no case of fever was contracted at the camp, 
and of the 1208 refugees who passed the required detention and 
proceeded to different parts of the country, so far as known, not 
one subsequently developed or carried the disease elsewhere. 



CAMPS OF PROBATION. 509 

The general plan of the preventive measures adopted during this 
epidemic will be described under Railroad Quarantine. 

Detention Gamp, Waynesville, Get. — The epidemic of 
yellow fever in Brunswick, Ga., in 1893, caused the establish- 
ment of another camp of probation near Waynesville, Ga. 
Following is the report of the medical officer in command : — 

Sir : I have the honor to present the following report of the opera- 
tions of the detention camp near Waynesville, Ga. 

The camp was officially opened for the reception of refugees from 
Brunswick, Ga., on the 18th of September, 1893, and closed by the order 
of Surgeon R. D. Murray, Marine-Hospital Service, permitting the 
return of all refugees to their homes in Brunswick. Xovernber 30, 1893. 

Four hundred and thirty-one persons availed themselves of the 
privileges of the camp, of whom about two hundred and twenty-five 
were white and the remainder black and colored. 

The site of the camp was selected by Surgeon "W. H. H. Hurt on. 
and was twenty-three miles west of Brunswick, immediately upon and 
on the south side of the Brunswick and Western Railway, and upon an 
eminence about twenty-five feet above the level of the surrounding coun- 
try, which is generallj- swamp}', and within a mile of the margin of 
what is locally known as the Buffalo Swamp. As is usual in this sec- 
tion, the elevation was covered with a dense growth of yellow-pine, 
scrub-oak, and black-gum trees. The soil was a gray, sandy loam, over- 
lying a stratum of yellow clay, and the natural drainage of the site in all 
directions was good. 

On my arrival I found that, under the direction of Surgeon Hut- 
ton, an area of two hundred feet had been cleared of trees and under- 
growth, and at the four corners of this square rough but substantial 
buildings had been erected, which were used, respectively, as kitchen, 
white and colored dining-rooms, guard-room, quartermaster's store-room, 
executive office, telegraph office, and commissary. A depot and baggage- 
room were provided at the railway. Along the lines connecting these 
buildings, at intervals of twelve feet, were placed wall-tents, twelve by 
fourteen feet, with flies, and subsequently further rows of tents were 
pitched behind these and opening on streets fourteen feet wide. All 
tents were provided with substantial floors raised six inches above the 
ground, and the following equipment was provided: For each inmate, 
one spring, wire-bottomed cot. one cotton mattress, one hair pillow, two 
sheets, one pillow-case, and, for each tent, two tin wash-bowls, two tin 
cups, and two wooden chairs. Remarkable ingenuity* was displayed by the 



5.30 a.m., . 




6.00 A.M., . 




8.00 A.M., 




12.00 m., 




4.00 p.m., 




5.00 p.m., 




Sunset, 




9.00 p.m., 




9.15 p.m., 




The meals i 


vere 



510 TEXT-BOOK OF HYGIENE. 

inmates in the construction of articles of furniture from packing-cases, 
waste lumber, etc. The tents proved of good quality in service, and 
quite comfortable in all weather. It is suggested, however, that any 
future tents be constructed with a wall two feet higher and of one foot 
greater pitch. A hospital establishment of two buildings was provided 
at a distance of one-half mile from the camp. A lofty pine-tree was 
fitted with a topmast, and served as a staff for the display of the 
national colors from sunrise to sunset each day. 

The following routine was observed, the calls being given by the 
bugle : — 

. Reveille and attendants' breakfast. 

. Breakfast. 

. Sick call. 

. Dinner. 

. Sick call. 

. Supper. 

. Retreat and call to quarters. 

. Tattoo. 

. Taps (extinguish lights), 
substantial, abundant, and as varied as possible. 
In all cases women and children were served at the first table, and the 
races were served in separate dining-rooms. 

The following rules were announced, and seemed to work well in 
practice : — 

1. At reveille all inmates will rise and prepare for breakfast. 

2. All quarters must be clean, floors swept, and beds made up 
before first sick call. 

3. Meals will be served in the dining-rooms only, and at stated 
hours, and no meals shall be carried from the dining-rooms to any quar- 
ters, except upon the written order of the medical officer, renewed from 
day to day. 

4. At sick calls all inmates will repair to their quarters, and be 
there visited and inspected by the medical officer, who will prescribe or 
advise as he may deem best. 

5. All suspicious cases of disease will be isolated at once, and until 
such time as the nature of the same may be determined. 

6. All cases of infectious disease will be treated only in the hos- 
pital provided for the purpose. 

7. No baggage from infected localities shall be brought into camp 
until disinfected by such process as may be directed, and only such 
wearing-apparel as may be deemed absolutely necessary will be brought 
into camp after the disinfecting process. 



CAMPS OF PROBATION. 511 

8. All wearing-apparel shall be a second time disinfected before 
discharge from camp. 

9. An} r person taken ill between two sick calls shall at once notify 
the nearest guard, who will, in turn, at once notify the medical officer. . 

10. Guards are enjoined by their vigilance to prevent the commis- 
sion of any nuisance near any quarters ; should such nuisance be discov- 
ered, the inmates of the nearest quarters will be required to police the 
same under the supervision of the guard, who will make report of the 
same. 

11. Inmates will confine themselves to the inner lines of the camp 
after retreat (sunset) call. 

12. While innocent enjoyment will be encouraged, the strictest pro- 
priety of conduct will be demanded and enforced. 

The discipline of the camp was, in the main, good throughout. But 
two confinements for misbehavior were required during the entire dura- 
tion of the camp. 

All baggage was submitted to steam disinfection upon arrival at 
and departure from camp. The apparatus used was devised by Surgeou 
H. R. Carter, Marine-Hospital Service, and was constructed in a baggage- 
car, the steam being supplied b} r a locomotive. 

In addition to other duties, nearly sixteen hundred cars, boxes, and 
flats were disinfected for the B. and W. Railwa} T , sulphur fumigation 
being used for the boxes and drenching with acid solution of bichloride 
of mercury (1 to 800) for flat cars. This disinfection of cars enabled 
the traffic into Brunswick to be carried on with a minimum of delay and 
hardship. 

Two cases of yellow fever occurred among the inmates of the camp, 
one resulting in recovery, one in death. Both cases occurred in the 
persons of sailors who had arrived in Brunswick on vessels trading there, 
and both would seem to show a period of incubation of at least five days, 
thus justifying our detention of ten days. 

Recommendations. — Experience having shown certain things to be 
desirable, I would respectfully recommend : — 

1st. That a disinfecting car be built and kept equipped for service 
in epidemics. 

The nine-foot chamber built by the Kensington Engine-Works of 
Philadelphia for this Service might be easily erected on a specially-con- 
structed car, and would prove more efficient in practice than extempo- 
rized apparatus. Another car might be fitted with apparatus for sulphur 
and bichloride-of-mercury disinfection, and a tank-car similar to those 
used for the transportation of petroleum would complete a train that 



512 TEXT-BOOK OF HYGIENE. 

would be always ready for emergencies in any part of the country. 
Steam could be supplied by a locomotive hired for the purpose. 

2d. That while experience has demonstrated the usefulness of tents, 
those provided in the future should be higher in the pitch and the wall, 
and that some provision be made for heating in severe weather. It is a 
question in my mind whether the Sible}^ conical tent, made with a higher 
wall, would not be preferable, on this account, to the square tent. 

3d. That in future epidemics of yellow fever apparatus be pro- 
vided for observations into temperature, temperature maximum and min- 
imum, barometric pressure, dew-point, direction and velocity of the wind, 
precipitation, and ozone. 

4th. That apparatus, instruments, and reagents be provided for in- 
vestigation into the etiology of yellow fever in future epidemics. 

Yery respectfully, 
(Signed) H. D. Geddings, 

P. A. Surgeon M.-H. S. 

To the Supervising Surgeon- General Marine-Hospital Service. 

RAILROAD QUARANTINE AND INSPECTION SERVICE. 

Railroad quarantine and inspection service may be described 
by a brief account of the actual measures of this nature made 
use of during the yellow- fever epidemic in Florida, in 1888, of 
which Camp Perry, just described, was an important adjunct. 
(For details, see annual reports Marine-Hospital Service, 1888 
and 1889.) 

The Governor of Florida made application to the national 
authorities, July 16th, for aid, and it was determined to prevent 
further spread of the disease by disinfecting all baggage from 
infected localities before permitting its transportation into other 
States, and by enforcing, upon all persons from infected localities 
seeking to leave the State, a probationary detention of ten days. 

Accordingly, disinfection stations were established at two 
points, through which all persons leaving Florida by rail were 
obliged to pass. One of these was at Live Oak, in North- 
western Florida; the other at Way Cross, Georgia, near the 
boundary-line of Northeastern Florida. The only other means 
of egress from the State was from the sea-ports ; but healthy 
sea-ports maintained a vigorous quarantine against people from 



RAILROAD QUARANTINE AND INSPECTION SERVICE. 513 

the infected districts, and infected sea-ports were not visited by 
the steam-ship lines, because their vessels would thereby be made 
liable to quarantine detention at other ports. The fumigation 
of baggage at Live Oak and Way Cross was accomplished by 
means of box-cars specially prepared, and subsequently in 
warehouses, the agent being sulphur dioxide. 

Regarding persons, the inspectors, properly uniformed and 
wearing official shields, boarded the trains when the latter arrived 
at the inspection stations, and demanded of each passenger a 
certificate, showing where he had been during the previous ten 
days, which certificate was considered valid only when it bore 
the seal or signature of some officer of health, or recognized 
municipal authority. The inspectors themselves were kept 
informed regarding all infected or suspected localities, and a 
person coming from such locality was either made to return to 
it or given the option of going to the camp of probation, there 
to spend the ten days' period of probation before being allowed 
to enter other States. 

This was Camp Perry, previously described, located 38 
miles south of the Way Cross Station, and 40 miles north of 
Jacksonville, where the epidemic prevailed chiefly. All egress 
from Jacksonville was, perforce, through Camp Perry and its ten 
days' probation. 

This camp was a means of protecting not only other States, 
but the uninfected portions of Florida itself, more particularly 
Southern Florida, whose health authorities refused to admit 
within their limits the refugees from the infected districts unless 
they had passed the period of probation at Camp Perry. To 
assist in this protection to Southern Florida, no person was 
allowed to board a south-bound train between Way Cross, 
on the north, and Orange Park, a station 20 miles south of 
Jacksonville. 

Moreover, through south-bound trains were boarded at 
Way Cross, and all passengers compelled to furnish evidence of 
coming from healthful localities. The evidence consisted of 



514 TEXT-BOOK OF HYGIENE. 

certificates from local authorities, baggage-checks, or railroad- 
tickets showing they were purchased in the North, and in some 
instances letters showing by the superscription and stamps 
where the person had been. 

No train, excepting the special government train, was 
allowed to stop at Camp Perry. A government train also 
carried those who had passed the period of probation from 
Camp Perry to a point 3 J miles distant, Folkstone, where they 
were transferred to a regular train running as far north as Way 
Cross, Ga., where another transfer had to be made to a regular 
north-bound train. No Florida passenger-car was allowed to 
go north, and more than 1000 baggage- and freight- cars were 
disinfected by government officers before being allowed to leave 
the State. 

Train- Inspection Service during the Brunswick Epidemic. 
— During the Brunswick epidemic the following regulations for 
the inspection of trains were promulgated and enforced : — 

Inspectors will allow none to board a train, unless with a certificate, 
between Way Cross and Savannah. 

If certificate can be examined before boarding, without detention 
to train, it must be done, and those which are unsatisfactory will not be 
allowed to board. 

After boarding, the certificate and the person must be carefully ex- 
amined and the inspector assure himself that the passenger is not recently 
from Jesup or any infected locality. 

If the passenger is known to be a recent resident of Jesup or any 
infected locality, or to have been in such place during the past two (2) 
weeks, he will not be allowed to board, even if he has a certificate. 

If, after boarding, either the certificate or the examination of pas- 
sengers is not satisfactory, the passenger will be turned over to the city 
authorities at Way Cross or Savannah, or at the place where he desires 
to stop. If between these places, the facts to be noted and reported. 

A record will be kept of the names of all passengers inspected, name 
of signer of certificate and his rank, date of inspection, date of certificate, 
and place of boarding train; and where passenger is bound and what dis- 
position is made of him, whether passed or turned over to local authori- 
ties ; also any other facts worth notice. 

Inspectors will aid local quarantine authorities in any way in their 



RAILROAD QUARANTINE AND INSPECTION SERVICE. 515 

power consistent with their duties, and give them any information, 
obeying all local quarantine regulations. Inspectors report to Surgeon 
Carter, United States Marine-Hospital Service, or A. P. English, M.D. 

Rules Adopted by Montgomery Conference for Railroad 
Quarantine. — The following are the rules for railroad quaran- 
tine adopted by the Quarantine Conference held in Montgomery, 
Ala., March 5 to 7, 1889 :— 

1. Quarantine should not be made against any place until it is 
officially known that yellow fever or other infectious or contagious dis- 
ease exists at such place. 

2. Only competent physicians should be put in charge of quaran- 
tine stations, and only thoroughly-qualified persons should be emploj^ed 
as inspectors on railway -trains. 

3. Quarantine stations located on railroads should be established 
at convenient points, on one or both sides of a town or station, as may 
be deemed necessary. 

4. If an epidemic of yellow fever or other infectious or contagious 
disease exist at a town or station, trains cariying passengers or freight 
should be required to pass through the limits of such towns or stations 
at a speed of not less than ten miles per hour, without stopping at such 
towns or stations, but should stop at the quarantine station. 

5. Passengers to or from such infected point should only be received 
or delivered at the quarantine station, under the supervision of the 
quarantine officer in charge of the station. 

6. Railway -tickets may be sold to persons leaving an infected place 
to any point willing to receive them. 

T. All baggage from any infected point should be properly disin- 
fected. 

8. As far as practicable, the same rules proposed for railroads 
should be applied to vessels of every kind, stage-coaches, or other means 
of travel. 

9. The passage of railroad-trains through any point on the line of 
road, whether infected or not, should not be prohibited by any quaran- 
tine regulations. The conductors of passenger-trains should close the 
windows and ventilators and lock the doors of cars passing through any 
place where a train is not permitted to stop. 

10. All freight to any infected place should be delivered either at 
the quarantine station or the nearest railway-station to such infected 
point where it can be properly cared for. 



516 TEXT-BOOK OF HYGIENE. 

11. All mail-matter from any infected place should be properly 
disinfected by the United States Government ; and mail-matter intended 
for infected points should be put off the trains at the quarantine stations. 
The United States Government should instruct postmasters to receive 
and deliver mails at such quarantine stations. 

12. Railroads and express companies may receive for transporta- 
tion from an}' infected place, during the time such infection exists, any 
merchandise or traffic consigned to places willing to receive it. 

13. State authorities should employ competent persons on passen- 
ger-trains as inspectors of passengers, baggage, and express matter, as 
additional precaution ; but the fact of inspectors being on such trains 
should not relieve trains carrying passengers or express matter or 
baggage from stopping at quarantine stations for such inspection as the 
officer in charge may determine to be necessary. 

14. It is recommended that all quarantines, as far as practicable, 
should be uniform in their requirements and operations, which will 
greatly contribute to the prevention of panics, and tend to allay un- 
necessary excitement and fear on the part of the people. 

15. The form of health certificate adopted by the Quarantine Con- 
vention held at Montgomery, March 5, 1889, should be prepared for 
health officers to issue to such persons as may be found entitled to re- 
ceive the same. A copy of this certificate should be printed with these 
rules, and conspicuously posted at railway-stations. 

16. It is the desire and intention of health authorities, as far as 
practicable, to throw every safeguard around the public health of all 
localities. Municipal, county, and State authorities are expected to 
co-operate in every possible way with health officers located in towns, 
villages, and cities, and in charge of quarantine stations, to enable them 
to prevent the introduction or spread of yellow fever or other infectious 
or contagious diseases. 

It was also resolved by this conference that the best form 
of disinfectant for personal baggage is moist heat. 

The methods of railroad quarantine may also be studied 
in a review of the action taken to prevent the introduction of 
small-pox into the United States from Canada, where it prevailed 
extensively in the fall and winter of 1885, and January and 
February, 1886. 

The following regulations were issued by the Surgeon- 
General of the Marine-Hospital Service, October 10, 1885 : — 



RAILROAD QUARANTINE AND INSPECTION SERVICE. 517 

The act approved April 29, 1878, entitled "An act to prevent the 
introduction of contagious or infectious diseases into the United States," 
provides that no vessel or vehicle coming from any foreign port or 
country where any contagious or infectious disease exists, or any vessel 
or vehicle conveying persons, merchandise, or animals affected with any 
contagious disease, shall enter any port of the United States, or pass the 
boundary-line between the United States and any foreign country, except 
in such manner as may be prescribed under said act. 

Attention is now directed to the prevalence of the contagious and 
infectious disease of small-pox in Montreal and other places in the Do- 
minion of Canada, and the law referred to is held to apply alike to trains 
of cars and other vehicles crossing the border, and to vessels entering 
ports on the northern frontier. 

Because, therefore, of the danger which attaches to the transporta- 
tion of persons and baggage, and articles of merchandise, or animals, 
from the infected districts, the following regulations are framed, under 
the direction of the Secretary of the Treasury, and subject to the ap- 
proval of the President, for the protection of the health of the people of 
the United States against the danger referred to : — 

1. Until further orders all vessels arriving from ports in Canada, 
and trains of cars and other vehicles crossing the border-line, must be 
examined b3 T a medical inspector of the Marine-Hospital Service before 
they will be allowed to enter the United States, unless provision shall 
have been made by State or municipal quarantine laws and regulations 
for such examination. 

2. All persons arriving from Canada, by rail or otherwise, must be 
examined by such medical inspector before they will be allowed to enter 
the United States, unless provision has been made for such examination. 

3. All persons coming from infected districts, not giving satisfac- 
tory evidence of protection against small-pox, will be prohibited from 
proceeding into the United States until after such period as the medical 
inspector, the local quarantine, or other sanitary officer duly authorized, 
may direct. 

4. The inspectors will vaccinate all unprotected persons, who desire 
or are willing to submit to vaccination, free of charge. Any such person 
refusing to be vaccinated shall be prevented from entering the United 
States. 

5. All baggage, clothing, and other effects, and articles of mer- 
chandise, coming from infected districts, and liable to carry infection, or 
suspected of being infected, will be subjected to thorough disinfection. 

6. All persons showing evidence of having had small-pox or vario- 
loid, or who exhibit a well-defined mark of recent vaccination, may be 



518 TEXT-BOOK OF HYGIENE. 

considered protected ; but the wearing-apparel and baggage of such pro- 
tected persons who may come from infected districts, or have been 
exposed to infection, will be subjected to thorough disinfection as pro- 
vided. 

7. Customs officers and United States medical inspectors will con- 
sult and act in conjunction with authorized State and local health author- 
ities so far as may be practicable, and unnecessary detention of trains or 
other vehicles, persons, animals, baggage, or merchandise, will be avoided 
so far as may be consistent with the prevention of the introduction of 
diseases dangerous to the public health into the United States. 

8. Inspectors will make full weekly reports of services performed 
under this regulation. 

9. As provided in Section 5 of said act, all quarantine officers or 
agents acting under any State or municipal system, upon the application 
of the respective State or municipal authorities, are empowered to enforce 
the provisions of these regulations, and are hereby authorized to prevent 
the entrance into the United States of any vessel or vehicle, person, 
merchandise, or animals prohibited under the act aforesaid. 

10. In the enforcement of these regulations there shall be no inter- 
ference with any quarantine laws or regulations existing under or to be 
provided for by any State or municipal authority. 

The following are the special instructions for the guidance 
of sanitary inspectors, issued by Surgeon H. W. Austin, in 
charge of the inspection service on the Canadian frontier from 
Buffalo, N. Y., to the Atlantic coast during the epidemic above 
referred to (see Marine-Hospital Report, 1886) : — 

Regulations for Sanitary Inspectors. 

The following instructions will be observed by the sanitary inspec- 
tor on the following-mentioned railroads crossing the United States 
boundaiy-line, — viz., the Grand Trunk Railway, at Rouse's Point, N. Y., 
and Island Pond, Yt. ; the Passumpsic Railroad, at Newport, Yt. ; the 
Central Yermont Railroad, at Highgate Springs or Saint Albans ; the 
Canada Atlantic, at Rouse's Point, X. Y., and the Southeastern Rail- 
way, at Richford, Yt. : — 

All persons bound for the United States coming from Montreal, or 
other places in Canada where small-pox prevails, must produce satisfac- 
tory evidence to the inspector that they are protected by a recent 
vaccination, or submit to this operation before they are allowed to cross 
the boundary -line. 



RAILROAD QUARANTINE AND INSPECTION SERVICE. 519 

Inspectors will vaccinate all unprotected persons free of charge. 

Persons coming from Montreal, or suburban villages, will be care- 
fully questioned as to their residence, whether small-pox has occurred in 
their families, or whether they have been in contact with the disease. 

Inquiries should also be made relative to their baggage, whether it 
consists of bedding, household goods, etc., likely to be infected ; and if 
any person or article of baggage is considered by the inspector infected 
or likely to introduce the disease into the country, he or it should not be 
permitted to cross the line into the United States. 

You may consider persons protected who may show evidence of 
having had the small-pox or varioloid, or who exhibit a well-defined mark 
of vaccination. Accept as evidence of protection a certificate from any 
physician in good standing that the person presenting the same has been 
successfully vaccinated. Should you doubt the validity or authenticity 
of the certificate, you may refuse an\- such person presenting the same 
the privilege of crossing the border unless he submits to vaccination. 
Baggage known to have come from any infected district, and believed to 
be infected, will be thoroughly fumigated with sulphur at Rouse's Point, 
Saint Albans, Richford, Newport, and Island Pond. 

Weekly reports should be made to Surgeon H. W. Austin, United 
States Marine-Hospital Service, Burlington, Yt., of the number of trains 
inspected, number of persons examined, number of persons vaccinated, 
number of pieces of baggage fumigated, and any other information 
relative to services performed by the inspector. 

It will be observed that all the railroads, five in number, 
over which passengers or freight might be brought direct from 
Canada into the New England States, were guarded. 

Besides the line commanded by Surgeon Austin (Atlantic 
coast to Buffalo), another line was under the direction of Passed 
Assistant Surgeon Wheeler, at points east of Buffalo, and still 
another on the Michigan frontier, under command of Surgeon 
W. H. Long. These lines were established at the request and 
with the co-operation of the authorities of the respective States. 
Thirty-six inspectors were employed at 37 stations, who exam- 
ined 49,631 persons on railroad-trains, vaccinated 16,547, and 
detained or sent back 603. The contents of more than 7000 
pieces of baggage were disinfected. The measures taken were 
successful. 



520 TEXT-BOOK OF HYGIENE. 

In 1893, at a time when there was imminent danger that 
cholera might be introduced into the sea-board cities of the 
United States and carried by immigrants to the far West and 
the interior cities and towns, a most carefully formulated plan 
of railroad medical inspection of immigrants was drawn up ; and 
while it was, fortunately, never necessary to carry out the pro- 
visions made at the time, the following regulations will well show 
the scope and general design of the protective and restrictive 
measures contemplated : — 

Railroad Medical Inspection of Immigrants. 

Treasury Department, 

Office of the Supervising Surgeon-General United States 

Marine-Hospital Service, 

Washington, August 23, 1893. 

Instructions for the Guidance of Medical Officers of the Marine-Hospital 
Service, Sanitary Inspectors, and others concerned. 

1. One or more medical inspectors shall accompany immigrants 
from the point of departure of each immigrant train, and shall im- 
mediately commence making a careful inspection of every passenger — 
man, woman, and child — upon the train. This inspection shall consist in 
identifying each passenger with the health card or cards he or she may 
hold, and satisfying himself as to the health of each person at the time 
of said inspection. He shall pass through the train once every hour or 
oftener, if he has reason to believe any person is suffering with diarrhoea 
or other symptoms of cholera. 

2. The railroad companies will be expected to furnish earth-closets, 
which should be used, and the regular closets of the car are to be locked. 
These earth-closets shall be destroyed, before the train reaches its des- 
tination, at such points as the railroad officials shall designate. It shall 
be the duty of the inspector to see that the earth-closets are kept clean 
and frequently disinfected, and the cars properly ventilated and free from 
all offensive odors and dirt. 

3. He shall, upon the least suspicion of cholera among the immi- 
grants, have the suspected person or persons immediately removed to 
the hospital car at the rear of the train, disinfect all ejecta, and take 
every precaution possible to prevent the spread of the disease among the 
passengers by thoroughly disinfecting that portion of the car occupied 
by the suspects, the simplest means for this purpose being a solution of 
bichloride of mercury in the proportion of 1 to 800. 



INTERSTATE QUARANTINE. 521 

4. The inspectors will at once notify the conductor of the train 
upon the first appearance of a suspicious case, in order that the hospital 
car may be switched off at the first designated switch, and the health 
officer of the county in which said switch is located be immediately 
notified to take charge of this car. 

5. It is expected that the railroads will furnish a car for hospital 
purposes, in which the seats can be readily converted into beds suitable 
for the care of the sick. The necessary bedding will be furnished by the 
United States Marine-Hospital Service. 

6. Disinfectants, consisting of packages of bichloride of mercury 
and an alkali, will be furnished the medical inspector in proper quantities 
for adding to a two-gallon wooden bucket of water ; also a quantity of 
carbolic acid in solution and other approved disinfectants. Each hospital 
car shall be equipped with a dozen two-gallon wooden buckets for holding 
disinfecting fluids, half a dozen mops, one or more hand force-pumps 
with rose sprinklers, one or more commodes and bed-pans, half a dozen 
eight-ounce hard-rubber syringes, half a dozen tumblers, one dozen 
rubber sheets, and one dozen feeding-cups for administering medicine. 
There shall also be furnished an oil-stove for heating water, and several 
tin boilers and tin cups. 

T. Medical supplies, etc.. consisting of tannic acid, hydrarg. chlori- 
dum mite, tincture of opium, mustard or mustard papers, chloroform or 
ether sulph.. whisky, brandy, and one or more hypodermatic syringes; 
also supply of Squibb 's Diarrhoea Mixture for checking looseness of the 
bowels or premonitory diarrhoea. 

Walter Wymaw, 
Supervising Surgeon-General. 

Interstate Quarantine. 

The general principles governing interstate quarantine are 
the same as those pertaining to the maritime and foreign quar- 
antines, with the exception that, instead of dealing with ships as 
the media of transportation, we must deal with trains on rail- 
roads, lines of stage-coaches, and steam-boats plying on the 
inland waters of the United States. The principles are almost 
sufficiently elaborated in the previous sections on train inspection 
in the case of yellow-fever epidemics, and the precautions which 
were under consideration for the prevention of the spread of 
cholera by means of emigrant trains. 

An important matter is the one of notification. It will be 



522 TEXT-BOOK OF HYGIENE. 

seen, by a study of the regulations for interstate quarantine 
which follow, that State and municipal health officers are 
requested to notify the Supervising Surgeon-General of the ap- 
pearance of any of the quarantinable diseases in their States or 
localities, thus enabling appropriate measures to be taken to 
prevent their spread without the loss of valuable time, for time 
in the management of epidemics is of the utmost importance. 
Many an epidemic which has assumed vast proportions would, 
if recognized in time, have been capable of easy management 
and of being confined to the seat of its first outbreak. It is 
always comparatively easy to confront an open enemy ; it is the 
insidious spread of disease, either unrecognized or concealed for 
reasons of business policy, that causes delay in the inception of 
preventive measures, and is most to be dreaded from a sanitary 
stand-point. 

The following are the regulations prepared in the Marine- 
Hospital Bureau to prevent the introduction of contagious dis- 
eases into one State or Territory or the District of Columbia from 
another State or Territory or District of Columbia. It is ex- 
pected that additional regulations will be promulgated from time 
to time as circumstances demand : — 

Interstate Quarantine. 

article i. — quarantine diseases. 

1. For the purpose of these regulations the quarantinable diseases 
are cholera (cholerine), yellow fever, small-pox, typhus fever, leprosy, and 
plague. 

ARTICLE II. NOTIFICATION. 

1. State and municipal health officers should immediately notify 
the Supervising Surgeon-General of the United States Marine-Hospital 
Service, by telegraph or by letter, of the existence of any of the above- 
mentioned quarantinable diseases in their respective States or localities. 

ARTICLE III. GENERAL REGULATIONS. 

1. Persons auffering from a quarantinable disease shall be isolated 
until no longer capable of transmitting the disease to others. Persons 
exposed to the infection of a quarantinable disease shall be isolated, 



INTERSTATE QUARANTINE. 523 

under observation, for such a period of time as may be necessary to 
demonstrate their freedom from the disease. 

All articles pertaining to such persons, liable to convey infection, 
shall be disinfected as hereinafter provided. 

2. The apartments occupied by persons suffering from quarantin- 
able disease, and adjoining apartments, when deemed infected, together 
with articles therein, shall be disinfected upon the termination of the 
disease. 

3. Communication shall not be held with the above-named persons 
and apartments, except under the direction of a duty-qualified officer. 

4. All cases of quarantinable disease, and all cases suspected of 
belonging to this class, shall be at once reported by the physician in 
attendance to the proper authorities. 

5. No common carrier shall accept for transportation any person 
suffering with a quarantinable disease, nor any infected article of clothing, 
bedding, or personal property. 

Bodies of persons who have died from any of the said diseases 
shall not be transported save in hermetically-sealed coffins, and by the 
order of the State or local health officer. 

6. In the event of the prevalence of small-pox, all persons exposed 
to the infection, who are not protected by vaccination or a previous 
attack of the disease, shall be at once vaccinated or isolated for a period 
of fourteen days. 

7. During the prevalence of cholera, all the dejecta of cholera 
patients shall be at once disinfected, as hereinafter provided, to prevent 
possible contamination of the food- and water- supply. 

ARTICLE IV. — YELLOW FEVER. 

In addition to the foregoing regulations contained in Article I, the 
following special provisions are made with regard to the prevention of 
the introduction and spread of yellow fever : — 

1. Localities infected with yellow fever, and localities contiguous 
thereto, should be depopulated as rapidly and as completely as possible, 
so far as the same can be safely done ; persons from non-infected locali- 
ties, and who have not been exposed to infection, being allowed to leave 
without detention. Those who have been exposed, or who came from 
infected localities, shall be required to undergo a period of detention and 
observation of ten daj^s, from the date of last exposure, in a camp of 
probation or other designated place. 

Clothing and other articles capable of conveying infection shall 
not be transported to non-infected localities without disinfection. 

2. Persons who have been exposed may be permitted to proceed 



524 TEXT-BOOK OF HYGIENE. 

without detention to places willing to receive them, and incapable of be- 
coming infected, when arrangements have been perfected to the satisfac- 
tion of the proper health officer to insure their detention in said places 
for a period of ten days. 

3. The suspects who are isolated under the provisions of paragraph 
1, Article III, shall be kept free from all possibility of infection. 

4. So far as possible the sick should be removed to a central loca- 
tion for treatment. 

5. Buildings in which yellow fever has occurred, and localities be- 
lieved to be infected with said disease, must be disinfected as thoroughly 
as possible. 

6. As soon as the disease becomes epidemic, the railroad-trains 
carrying persons allowed to depart from the city or place infected with 
yellow fever shall be under medical supervision. 

7. Common carriers from the infected districts, or believed to be 
canying persons and effects capable of conveying infection, shall be sub- 
ject to sanitary inspection, and such persons and effects shall not be 
allowed to proceed, except as provided for by paragraph 2. 

8. At the close of an epidemic the houses where sickness has 
occurred, and the contents of the same, and houses and contents that 
are presumably infected, shall be disinfected as hereinafter prescribed. 



ARTICLE V. — DISINFECTION. 

For Cholera. 

1. The dejecta and vomited matters of cholera patients shall be 
received into vessels containing an acid solution of bichloride of mer- 
cury (bichloride of mercury, 1 part; hydrochloric acid, 2 parts; water, 
1000 parts) or other efficient germicidal agent. 

2. All bedding, clothing, and wearing-apparel soiled by the dis- 
charges of cholera patients shall be disinfected by one of more of the 
following methods : — 

(a) By complete immersion for thirty minutes in one of the above- 
named disinfecting solutions. 

(b) By boiling for fifteen minutes, all articles to be completely sub- 
merged. 

(c) By exposure to steam at a temperature of 100° to 102° C. for 
thirty minutes after such temperature is reached. 

3. An} r woodwork or furniture contaminated by cholera discharges 
shall be disinfected by thorough washing with a germicidal solution as 
provided in paragraph 1, Article V. 



INTERSTATE QUARANTINE. 525 

For Yellow Fever. 

4. Apartments infected by occupancy of patients sick with yellow 
fever shall be disinfected b}^ one or more of the following methods : — 

(a) By thorough washing with one of the germicidal solutions 
mentioned. If apprehension is felt as to the poisonous effects of the 
mercury, the surfaces may, after two hours, be washed with clear water. 

(b) Thorough washing with a 5-per-cent. solution of pure carbolic 
acid. 

(c) By sulphur dioxide, twenty-four to forty-eight hours' exposure, 
the apartments to be rendered as air-tight as possible. 

5. Bedding, wearing-apparel, carpets, hangings, and draperies 
infected by yellow fever shall be disinfected by one of the following 
methods : — 

(a) By exposure to steam at a temperature of 100° to 102° C. for 
thirty minutes after such temperature is reached. 

(b) By boiling for fifteen minutes, all articles to be completely 
submerged. 

(c) By thorough saturation in a solution of bichloride of mercury, 
1 to 1000, the articles being allowed to dry before washing. 

Articles injured by steam (rubber, leather, containers, etc.), to the 
disinfection of which steam is inapplicable, shall be disinfected by thor- 
oughly wetting all surfaces with (a) a solution of bichloride of mercury 
1 to 800, or (6) a 5-per-cent. solution of carbolic acid, the articles being 
allowed to dry in the open air prior to being washed with water, or (c) 
by exposure to sulphur fumigation in an apartment air-tight, or as nearly 
so as possible. 

For Small-pox. 

6. Apartments infected by small-pox shall be disinfected by one or 
both of the following methods : — 

(a) Exposure to sulphur dioxide for twenty-four to forty-eight 
hours. 

(b) Washing with a solution of bichloride of mercury 1 to 1000, or a 
5-per-cent. solution of pure carbolic acid. 

7. Clothing, bedding, and articles of furniture exposed to the infec- 
tion of small-pox shall be disinfected by one or more of the following 
methods : — 

(a) Exposure to sulphur dioxide for twenty-four to forty-eight 
hours. 

(6) Immersion in a solution of bichloride of mercury 1 to 1000, or 
a 5-per-cent. solution of pure carbolic acid. 

(c) Exposure to steam at a temperature of 100° to 102° C. for 
thirty minutes after such temperature is reached. 



526 TEXT-BOOK OF HYGIENE. 

(d) Boiling for fifteen minutes, the articles to be completely sub- 
merged. 

For Typhus Fever. 

8. Apartments infected by typhus fever shall be disinfected by one 
or botli of the following methods : — 

(a) Exposure to sulphur dioxide for twenty-four to forty-eight 
hours. 

(6) Washing with a solution of bichloride of mercury 1 to 1000, or a 
5-per-cent. solution of pure carbolic acid. 

9. Clothing, bedding, and articles of furniture exposed to the infec- 
tion of typhus fever, shall be disinfected by one or more of the following 
methods : — 

(a) Exposure to sulphur dioxide for twenty-four to forty-eight 
hours. 

(b) Immersion in a solution of bichloride of mercury 1 to 1000, or a 
5-per-cent. solution of pure carbolic acid. 

(c) Exposure to steam at a temperature of 100° to 102° C. for 
thirt}- minutes after such temperature is reached. 

(d) Boiling for fifteen minutes, the articles to be completely sub- 
merged. 

Municipal Quarantine. 
It is now generally conceded that a small number of cases 
of certain ones of the quarantinable diseases may exist in a city 
of considerable size, without giving rise to serious apprehension, 
if intelligent and vigorous measures for the prevention of its 
spread are taken, and if scientific measures for the isolation of 
patients, the surveillance of those exposed to infection, and the 
disinfection of apartments and articles infected are carried out. 
It is regarded as very important that the sick should be removed 
to centrally-located hospital establishments for treatment, thus 
increasing ease of management and administration, and dimin- 
ishing the number of foci of infection. The surveillance of 
those exposed to infection should, in general, be for a period of 
time equal to the usual period of incubation of the disease to 
which they have been exposed. In the case of small-pox it may 
be unnecessary at times to detain the suspects the full period of 
incubation, provided they are vaccinated and their clothing and 



MUNICIPAL QUARANTINE. 527 

personal effects are rendered safe by efficient disinfection. They 
should, however, be kept under observation. 

For the suppression of small-pox in cities in which it has 
made its appearance, and in which it threatens to become epi- 
demic, the following suggestions, made by the health authorities 
of the Northwest, will undoubtedly prove of value : — 

1. The city should be divided into districts containing not more 
than 10,000 people. 

2. Each district should be placed under the supervision of a compe- 
tent medical inspector with necessary assistants (a) to make a house- 
to-house inspection ; (b) to successfully vaccinate, within the shortest 
possible time, all persons who have not been vaccinated during the out- 
break, the first vaccination to be completed within seven daj-s ; (c) to 
properly disinfect all houses and their contents where small-pox occurs. 

3. Necessary means and appliances for efficient disinfection of ma- 
terials, premises, etc., should be provided as the exigencies of each district 
may require. 

4. Each case of small-pox should be immediately removed to a 
suitably constructed and properly equipped and officered isolation 
hospital. 

5. Except in extreme cold weather, hospital tents, as prescribed in 
the United States Army Regulations, floored and warmed, are preferable 
to the average hospital or private dwelling, and increase the chances of 
recovery of the patients. Cases of small-pox necessarily retained in their 
own homes should, with their attendants, be rigidly isolated during the 
period of danger, and physicians visiting such patients professionally 
should be subject to such regulations as may be prescribed by the local 
health officer. 

6. Persons exposed to small-pox contagion should be immediately 
vaccinated and kept under observation for not less than fourteen days 
from time of last exposure. 

7. It is the sense of this Conference that unless such measures are 
enforced, it will be necessaiy for neighboring cities and States to exclude 
all persons from such city who are not protected against small-pox by 
recent vaccination, and to require proper disinfection of all clothing, bag- 
gage, and merchandise capable of convejung small-pox infection. 

The subject of municipal quarantine naturally suggests a 
subdivision of the subject, viz., domiciliary quarantine, or the ex- 
ercise of restrictive measures against a particular house or part 



528 TEXT-BOOK OF HYGIENE. 

of a house on account of the occurrence of a quarantinable dis- 
ease within its limits. These can best be accomplished by the 
stationing of guards to see that none enter or leave the infected 
premises except those necessary to care for the sick, viz., phy- 
sicians and nurses. All intercourse between the outside world 
and the house under quarantine should be carried on by 
messengers who should not be allowed to enter the premises, 
but who should report to the guards. 

It would be most desirable that the physicians and nurses, 
on leaving the premises, should practice personal disinfection of 
hands, at least; though, of course, it would be better if, in ad- 
dition to this, a change into sterile clothing were made prior to 
coming into contact with the public. 

It goes without saying that the room of the patient should 
be absolutely closed to the ingress of all save the physicians and 
nurses, and it is a practice of considerable value to provide all 
room-openings with curtains or hangings, which are to be kept 
constantly wet with a germicidal solution. The dejecta, vomited 
matter, and sputum should be promptly disinfected according to 
circumstances. When the disease has terminated, the house or 
apartments are to be thoroughly disinfected by one of the 
methods prescribed in the regulations, the method chosen being 
adapted to the disease which has prevailed. For the purposes 
of municipal disinfection the Marine-Hospital Service has had 
constructed portable apparatus for the use of steam and sulphur, 
which are, in effect, the same apparatus as have been previously 
described in this article, modified to meet their special require- 
ments. 

An important factor in the measures taken to suppress any 
epidemic disease is a house-to-house inspection, to ascertain 
the actual number of cases existing. Whether this inspection 
should include the whole city, or only the infected district, is a 
matter for the exercise of judgment ; but, when required, the in- 
spections should be made at intervals corresponding with the 
usual periods of incubation of the disease under observation. 



DIPHTHERIA AND SCARLET FEVER. 529 

A very important field for the exercise of municipal and 
domiciliary quarantine is furnished by those contagious and in- 
fectious diseases which, while causing large mortality, seldom 
prevail in epidemic form, viz., measles, scarlet fever, diphtheria, 
and tuberculosis. 

MEASLES. 

Measles may be dismissed with a few words. The course 
of the disease, uncomplicated, is usually so benign, especially in 
children, that all that is necessary is isolation. At the conclusion 
of the case or cases the apartment should be well aired, and it 
may be advisable to subject the room and the contents, bedding, 
and clothing to fumigation by sulphur. 

DIPHTHERIA AND SCARLET FEVER. 

With diphtheria and scarlet fever the conditions are far 
different. The diseases are virulent: the infection is subtle, and 
their spread very much to be dreaded. Vigorous effort alone can 
prevent their spread. Dwellings where the disease prevails 
must be placarded, special hospitals should be provided, and 
disinfection should be intelligently performed by competent 
municipal authority. 

The regulations of the Board of Health of the District of 
Columbia are given here, as embodying the most recent practice 
in the management of these diseases : — 

Regulations to Prevent the Spread of Diphtheria and Scarlet 

Fever. 

The following regulations, provided for in the Act of Congress 
approved December 20, 1890, are promulgated for the information of all 
concerned : 

The act referred to provides, in Section 2, " That it shall be the 
duty of the health officer, in conjunction with the attending physician, 
to cause the premises to be properly disinfected, and to issue the neces- 
sary instructions for the isolation of the patient "; in Section 3, " That 
it shall be the duty of physicians, while in attendance upon cases of 
scarlet fever and diphtheria, to exercise such reasonable precautions to 
prevent the spread of the said diseases as may be prescribed by the 

34 



530 TEXT-BOOK OF HYGIENE. 

health officer of the District of Columbia in regulations n ; in Section 6, 
" That the word ' regulations,' as herein used, shall be held to mean, also, 
rules, orders, and amendments." 

The term " scarlet fever," as applied in the act, shall be held to in- 
clude scarlatina, scarlet rash, and canker rash, and each and every case 
must be reported upon the forms provided. 

Warning-signs shall remain displayed on houses, in cases of scarlet 
fever, for a period of not less than four weeks, and in cases of diphtheria 
for not less than three weeks from date of report to the health officer, 
and for a longer period, unless report of recovery by the physician in 
attendance has been made. 

In cases of death, the warning-sign shall remain displayed upon 
premises for a period of not less than seven days, and longer, unless the 
health officer is satisfied that all proper means have been employed for 
prevention of the spread of the contagion. 

It shall be the duty of the householder, in every case where a 
warning-sign has been displayed from the premises which he or she occu- 
pies, to report promptly the removal of such sign at any time within the 
periods given. 

It shall be the like duty of the physician in attendance to make 
such report to the health officer of the removal of warning-signs, unless 
assured that the report has been made by some one from the premises 
where the disease is prevailing or has prevailed. 

It shall be the duty of the physician in attendance to report, in 
every instance, on the forms provided, whether or not children in the 
family or other children in the same building attend school, and at what 
school-building or buildings. 

Children shall not be permitted to return to school from infected 
premises, except upon presentation of the proper certificate from the 
health officer. 

All persons suffering from either diphtheria or scarlet fever are to 
be isolated in rooms as far removed as possible from those occupied by 
other persons in the building, and upon the top floor, where it is prac- 
ticable. No person, other than the physician in attendance, the examin- 
ing official, and the nurse or nurses, shall be admitted to such room 
during the prevalence of the disease. 

Every room occupied by a patient suffering from either diphtheria 
or scarlet fever shall be cleared of all needless clothing, carpets, drapery, 
and other materials likely to harbor the poisons of the disease. 

Soiled bed- and body- linen shall be immediately placed in vessels 
of water containing a solution of bichloride of mercury, chloride of zinc, 
or other suitable disinfectant. 



DIPHTHERIA AND SCARLET FEVER. 531 

Excremental discharges from the patient shall be received in vessels 
of water containing such a solution, and all vessels used shall be kept 
scrupulously clean and thoroughly disinfected. 

Discharges from the throat, nose, and mouth shall be received upon 
pieces of cloth, which must be immediately burned. 

All persons recovering from either diphtheria or scarlet fever shall 
be considered dangerous, and shall not be permitted to associate with 
others, or to attend school, church, or any public assembly, until a cer- 
tificate has been furnished by the health officer to the effect that they 
may go abroad without danger of disseminating the contagion. 

It shall be the duty of the person in charge of the premises where 
a case of diphtheria or scarlet fever exists, to exercise all reasonable care 
in the prevention' of the commingling of persons who come into contact 
with the patient, or any other persons, whereby the contagion might be 
disseminated. 

The body of a person who has died from either diphtheria or scarlet 
fever shall be immediately disinfected and placed in a coffin, which shall 
be tightly closed, and shall not be taken to any church or place of public 
assembly, and shall be buried within forty-eight hours, unless otherwise 
ordered by the health -officer. 

No public funeral shall be held in a dwelling in which there is a 
case of either diphtheria or scarlet fever, nor in which a death from either 
of said diseases has recently occurred. 

Immediately upon the recovery of a person who has been suffering 
from either diphtheria or scarlet fever, or upon the death of a person 
who has been so suffering, the room or rooms occupied shall be 
thoroughly disinfected \>y exposure for several hours to the fumes of 
chlorine gas, or of burning sulphur, and shall thereafter be thoroughly 
cleaned and exposed to currents of fresh air. 

All clothing, bedding, carpets, and other textiles which have been 
exposed to the contagion of the disease shall be either burned, exposed 
to superheated steam, or thoroughly boiled. 

No person shall interfere with or obstruct the entrance, inspection, 
and examination of any building or house, by the inspectors or officers 
of this department, when there has been reported the case of a person 
sick with either scarlet fever or diphtheria therein. 

Diagnosis of Diphtheria. — For the more prompt and cer- 
tain diagnosis of diphtheria, small wooden boxes are distributed 
to the various pharmacies in Washington, each box holding two 
glass tubes, one tube containing a small cotton swab, the other 



532 TEXT-BOOK OF HYGIENE. 

containing solidified blood-serum as a culture medium. Each 
tube is sterilized and plugged with cotton. The following 
notice is inclosed in each box : — 

Directions for Making Cultures in Suspected Cases of Diphtheria. 

The patient should be placed in the best light attainable, and, if a 
child, properly held. In cases where it is possible to get a good view of 
the throat, depress the tongue and rub the cotton swab gently, but freely, 
against any visible pseudomembrane or exudate. 1 

In other cases, including those in which the exudate is confined to 
the larynx, open the mouth and pass the swab back till it reaches the 
pharynx, and then rub it freely against the mucous membrane. Without 
laying the swab down, withdraw the cotton plug from the culture-tube, 
insert the swab, and rub that portion of it which has touched the exudate 
gently back and forth along the surface of the blood-serum. Then 
replace the swab in its own tube, plug both tubes, and send the whole 
outfit at once to the laboratory. 

A report will be forwarded the following morning, by mail, or can 
be obtained by telephone. 

TUBERCULOSIS. 

With the discovery by Koch of the cause of tuberculosis, 
and the numerous researches made by him and other observers 
into the nature of the tuberculous poison, has grown the con- 
viction, of late years, that tuberculosis, being communicable, 
is to a large extent preventable. The bacillus tuberculosis is 
the etiological factor of most importance in the spread of tuber- 
culosis ; it has been proved that it is contained in large numbers 
in the sputum of tuberculous patients, and that, unlike most 
micro-organisms, its vitality is not destroyed by drying. There- 
fore, with the careful disinfection or destruction of the expecto- 
ration of tuberculous patients, one most important factor in the 
dissemination of tuberculosis will be removed. In almost all 
large hospitals, at the present day, the practice obtains of either 
isolating the tuberculous patients or of segregating them in 
special wards or apartments. With a view of preventing the 
spread of tuberculosis, the Board of Health of New York City 

1 This should be done before any germicide has been applied, and, if this has been done, 
allow at least an hour to intervene before making the inoculation. 



TUBERCULOSIS. 533 

has issued in English, German, Hebrew, and Italian the follow- 
ing circular for popular instruction : — 

Consumption is a disease which can be taken from others, and is 
not simply caused by colds. A cold may make it easier to take the dis- 
ease. It is usually caused by germs which enter the bod} T with the air 
breathed. The matter which consumptives cough or spit up contains 
these germs in great numbers ; frequently millions are discharged in a 
single day. This matter, spit upon the floor, wall, or elsewhere, is apt 
to dry, become pulverized, and float in the air as dust. This dust con- 
tains the germs, and thus they enter the body with the air breathed. 
The breath of a consumptive does not contain the germs, and will not 
produce the disease. A well person catches the disease from a con- 
sumptive only by in some way taking the matter coughed up by the 
consumptive. 

Consumption can often be cured if its nature is recognized early 
and proper means are taken for its treatment. In a majority of cases it 
is not a fatal disease. 

It is not dangerous for other persons to live with a consumptive if 
the matter coughed up by the consumptive is at once destroyed. This 
matter should not be spit upon the floor, carpet, stove, wall, or street, or 
anywhere except into a cup kept for that purpose. The cup should con- 
tain water, so that the matter may not dry, and should be emptied into 
the closet at least twice a day, and carefully washed with hot water. 
Great care should be taken by a consumptive that his hands, face, and 
clothing do not become soiled with the matter coughed up. If thej^ do 
become soiled, they should be at once washed with hot water and soap. 
When consumptives are awa}^ from home, the matter coughed up may be 
received on cloths, which should be at once burned on returning home. 
If handkerchiefs are used (worthless cloths which can be burned are 
far better), they should be boiled in water by themselves before being 
washed. 

It is better for a consumptive to sleep alone, and his bed-clothing 
and personal clothing should be boiled and washed separately from the 
clothing belonging to other people. 

Whenever a person is thought to be suffering from consumption, 
the name and address should be sent at once to the health department, 
on a postal card, with a statement of this fact. A medical inspector 
from the health department will then call and examine the person to see 
if he has consumption, providing he has no physician, and, if necessary, 
will give proper direction to prevent others from catching the disease. 

Frequently a person suffering from consumption may not only 



534: TEXT-BOOK OF HYGIENE. 

do his usual work without giving the disease to others, but may also get 
well, if the matter coughed up is properly destroyed. 

Rooms that have been occupied by consumptives should be thor- 
oughly cleaned, scrubbed, whitewashed, painted or papered before they 
are again occupied. Carpets, rugs, bedding, etc., from rooms which 
have been occupied by consumptives, should be disinfected. The health 
department should be notified, when they will be sent for, disinfected, 
and returned to the owner free of charge ; or, if he so desire, they will 
be destroyed. 

QUARANTINE LAWS OF THE UNITED STATES. 

AN ACT granting additional quarantine powers and imposing additional duties upon 
the Marine-Hospital Service. 

[Approved February 15, 1893.] 

Be it enacted by the Senate and Souse of Representatives of the 
United States of America in Congress assembled, That it shall be unlaw- 
ful for any merchant ship or other vessel from any foreign port or place 
of [to] enter any port of the United States except in accordance with 
the provisions of this act and with such rules and regulations of State 
and municipal health authorities as may be made in pursuance of, or 
consistent with, this act ; and any such vessel which shall enter, or 
attempt to enter, a port of the United States in violation thereof shall 
forfeit to the United States a sum, to be awarded in the discretion of the 
court, not exceeding five thousand dollars, which shall be a lien upon 
said vessel, to be recovered by proceedings in the proper district court 
of the United States. In all such proceedings the United States Dis- 
trict Attorney for such district shall appear on behalf of the United 
States ; and all such proceedings shall be conducted in accordance with 
the rules and laws governing cases of seizure of vessels for violation of 
the revenue laws of the United States. 

Sec. 2. That any vessel at any foreign port clearing for any port or 
place in the United States shall be required to obtain from the consul, 
vice-consul, or other consular officer of the United States at the port of 
departure, or from the medical officer where such officer has been de- 
tailed by the President for that purpose, a bill of health, in duplicate, in 
the form prescribed by the Secretary of the Treasury, setting forth the 
sanitary history and condition of said vessel, and that it has in all re- 
spects complied with the rules and regulations in such cases prescribed 
for securing the best sanitary condition of the said vessel, its cargo, 
passengers, and crew ; and said consular or medical officer is required, 
before granting such duplicate bill of health, to be satisfied that the 
matters and things therein stated are true ; and for his services in that 



QUARANTINE LAWS OF THE UNITED STATES. 535 

behalf he shall be entitled to demand and receive such fees as shall by 
lawful regulation be allowed, to be accounted for as is required in other 
cases. 

The President, in his discretion, is authorized to detail any medical 
officer of the government to serve in the office of the consul at any 
foreign port for the purpose of furnishing information and making the 
inspection and giving the bills of health hereinbefore mentioned. An}^ 
vessel clearing and sailing from any such port without such bill of 
health, and entering any port of the United States, shall forfeit to the 
United States not more than five thousand dollars, the amount to be 
determined by the court, which shall be a lien on the same, to be recov- 
ered by proceedings in the proper district court of the United States. 
In all such proceedings the United States District Attorney for such dis- 
trict shall appear on behalf of the United States ; and all such proceed- 
ings shall be conducted in accordance with the rules and laws governing 
cases of seizure of vessels for violation of the revenue laws of the United 
States. 

Sec. 3. That the Supervising Surgeon-General of the Marine-Hos- 
pital Service shall, immediately after this act takes effect, examine the 
quarantine regulations of all State and municipal boards of health, and 
shall, under the direction of the Secretar} T of the Treasury, co-operate 
with and aid State and municipal boards of health in the execution and 
enforcement of the rules and regulations of such boards and in the ex- 
ecution and enforcement of the rules and regulations made by the Sec- 
retary of the Treasury to prevent the introduction of contagious or 
infectious diseases into the United States from foreign countries, and 
into one State or Territory or the District of Columbia from another 
State or Territory or the District of Columbia; and all rules and reg- 
ulations made by the Secretary of the Treasury shall operate uniformly 
and in no manner discriminate against any port or place ; and at such 
ports and places within the United States as have no quarantine reg- 
ulations under State or municipal .authority, w T here such regulations are, 
in the opinion of the Secretary of the Treasury, necessary to prevent 
the introduction of contagious or infectious diseases into the United 
States from foreign countries, or into one State or Territory or the Dis- 
trict of Columbia from another State or Territory or the District of 
Columbia, and at such ports and places within the United States where 
quarantine regulations exist under the authority of the State or munici- 
pality which, in the opinion of the Secretary of the Treasury, are not 
sufficient to prevent the introduction of such diseases into the United 
States, or into one State or Territory or the District of Columbia from 
another State or Territory or the District of Columbia, the Secretary of 



536 TEXT-BOOK OF HYGIENE. 

the Treasury shall, if in his judgment it is necessary and proper, make 
such additional rules and regulations as are necessary to prevent the in- 
troduction of such diseases into the United States from foreign countries, 
or into one State or Territory or the District of Columbia from another 
State or Territory or the District of Columbia; and when said rules and 
regulations have been made they shall be promulgated by the Secretary 
of the Treasury and enforced by the sanitary authorities of the States and 
municipalities, where the State or municipal health authorities will un- 
dertake to execute and enforce them ; but if the State or municipal au- 
thorities shall fail or refuse to enforce said rules and regulations, the 
President shall execute and enforce the same and adopt such measures 
as in his judgment shall be necessary to prevent the introduction or 
spread of such diseases, and may detail or appoint officers for that pur- 
pose. The Secretary of the Treasury shall make such rules and regula- 
tions as are necessary to be observed by vessels at the port of departure 
and on the voyage, where such vessels sail from any foreign port or place 
to an 3' port or place in the United States, to secure the best sanitary 
condition of such vessel, her cargo, passengers, and crew ; which shall be 
published and communicated to and enforced by the consular officers of 
the United States. None of the penalties herein imposed shall attach to 
any vessel or owner or officer thereof until a copy of this act, with the 
rules and regulations made in pursuance thereof, has been posted up in 
the office of the consul or other consular officer of the United States for 
ten days, in the port from which said vessel sailed ; and the certificate 
of such consul or consular officer over his official signature shall be 
competent evidence of such posting in any court of the United States. 

Sec. 4. That it shall be the duty of the Supervising Surgeon-Gen- 
eral of the Marine-Hospital Service, under the direction of the Secretary 
of the Treasury, to perform all the duties in respect to quarantine and 
quarantine regulations which are provided for by this act, and to obtain 
information of the sanitary condition of foreign ports and places from 
which contagious and infectious diseases are or may be imported into the 
United States ; and to this end the consular officer of the United States, 
at such ports and places as shall be designated by the Secretary of the 
Treasury, shall make to the Secretary of the Treasury weekly reports of 
the sanitary condition of the ports and places at which they are respect- 
ively stationed, according to such forms as the Secretary of the Treasury 
shall prescribe ; and the Secretary of the Treasury shall also obtain, 
through all sources accessible, including State and municipal sanitary 
authorities throughout the United States, weekly reports of the sanitary 
condition of ports and places within the United States, and shall pre- 
pare, publish, and transmit to collectors of customs and to State and 



QUARANTINE LAWS OF THE UNITED STATES. 537 

municipal health officers and other sanitarians weekly abstracts of the 
consular sanitary reports and other pertinent information received by 
him ; and shall also, as far as he may be able, by means of the voluntary 
co-operation of State and municipal authorities, of public associations, 
and private persons, procure information relating to the climatic and 
other conditions affecting the public health, and shall make an annual 
report of his operations to Congress, with such recommendations as he 
may deem important to the public interests. 

Sec. 5. That the Secretary of the Treasury shall from time to time 
issue to the consular officers of the United States and to the medical 
officers serving at any foreign port, and otherwise make publicly known, 
the rules and regulations made by him, to be used and complied with by 
vessels in foreign ports, for securing the best sanitary condition of such 
vessels, their cargoes, passengers, and crew, before their departure for 
any port in the United States, and in the course of the voyage ; and all 
such other rules and regulations as shall be observed in the inspection 
of the same on the arrival thereof at any quarantine station at the port 
of destination, and for the disinfection and isolation of the same, and the 
treatment of cargo and persons on board, so as to prevent the introduc- 
tion of cholera, yellow fever, or other contagious or infectious diseases ; 
and it shall not be lawful for any vessel to enter said port to discharge 
its cargo or land its passengers, except upon a certificate of the health 
officer at such quarantine station certifying that said rules and regula- 
tions have in all respects been observed and complied with, as well on 
his part as on the part of the said vessel and its master, in respect to the 
same and to its cargo, passengers, and crew ; and the master of every 
such vessel shall produce and deliver to the collector of customs at said 
port of entry, together with the other papers of the vessel, the said bills 
of health required to be obtained at the port of departure and the cer- 
tificate herein required to be obtained from the health officer at the port 
of entry ; and that the bills of health herein prescribed shall be con- 
sidered as part of the ship's papers, and when duly certified to by the 
proper consular officer or other officer of the United States, over his 
official signature and seal, shall be accepted as evidence of the statements 
therein contained in any court of the United States. 

Sec. 6. That on the arrival of an infected vessel at any port not 
provided with proper facilities for treatment of the same, the Secretary 
of the Treasury may remand said vessel, at its own expense, to the 
nearest national or other quarantine station, where accommodations and 
appliances are provided for the necessary disinfection and treatment of 
the vessel, passengers, and cargo; and after treatment of any infected 
vessel at a national quarantine station, and after certificate shall have 



538 TEXT-BOOK OF HYGIENE. 

been given l>3 r the United States quarantine officer at said station that 
the vessel, cargo, and passengers are each and all free from infectious 
disease, or danger of conveying the same, said vessel shall be admitted 
to entry to aii} T port of the United States named within the certificate. 
But at any ports where sufficient quarantine provision has been made 
hy State or local authorities the Secretary of the Treasury may direct 
vessels bound for said ports to undergo quarantine at said State or local 
station. 

Sec. 7. That whenever it shall be shown to the satisfaction of the 
President that by reason of the existence of cholera or other infectious 
or contagious diseases in a foreign country there is serious danger of the 
introduction of the same into the United States, and that notwithstanding 
the quarantine defense this danger is so increased by the introduction of 
persons or property from such country that a suspension of the right to 
introduce the same is demanded in the interest of the public health, the 
President shall have power to prohibit, in whole or in part, the introduc- 
tion of persons and property from such countries or places as he shall 
designate and for such period of time as he may deem necessary. 

Sec. 8. That whenever the proper authorities of a State shall sur- 
render to the United States the use of the buildings and disinfecting 
apparatus at a State quarantine station, the Secretary of the Treasury 
shall be authorized to receive them and to pay a reasonable compensa- 
tion to the State for their use, if in his opinion they are necessa^ to the 
United States. 

Sec. 9. That the act entitled " An act to prevent the introduction 
of infectious or contagious diseases into the United States, and to es- 
tablish a national board of health," approved March 3, 1819, be, and 
the same is hereby, repealed. And the Secretary of the Treasury is 
directed to obtain possession of any property, furniture, books, paper 
or records belonging to the United States which are not in the posses- 
sion of an officer of the United States under the Treasury Department 
which were formerly in the use of the National Board of Health or any 
officer or employe thereof. 

REVISED STATUTES. 

Sec ^794. There shall be purchased or erected, under the orders 
of the President, suitable warehouses, with wharves and in closures, 
where merchandise may be unladen and deposited, from any vessel 
which shall be subject to a quarantine or other restraint, pursuant to 
the health laws of any State, at such convenient places therein as the 
safety of the public revenue and the observance of such health laws may 
require. 



QUARANTINE LAWS OF THE UNITED STATES. 539 

Sec. 4795. Whenever the cargo of a vessel is unladen at some other 
place than the port of entry or delivery under the foregoing provisions, 
all the articles of such cargo shall be deposited at the risk of the parties 
concerned therein, in such public or other warehouses or inclosures as 
the collector shall designate, there to remain under the joint custody of 
such collector and of the owner, or master, or other person having charge 
of such vessel, until the same are entirely unladen or discharged, and 
until the articles so deposited may be safely removed without contra- 
vening such health laws. And when such removal is allowed, the col- 
lector having charge of such articles may grant permits to the respective 
owners or consignees, their factors or agents, to receive all merchandise 
which has been entered, and the duties accruing upon which have been 
paid, upon the payment by them of a reasonable rate of storage ; which 
shall be fixed by the Secretary of the Treasury for all public warehouses 
and inclosures. 

Sec. 4796. The Secretary of the Treasury is authorized, whenever 
a conformity to such quarantines and health laws requires it, and in 
respect to vessels subject thereto, to prolong the terms limited for the 
entry of the same, and the report or entry of their cargoes, and to vary 
or dispense with any other regulations applicable to such reports or 
entries. No part of the cargo of any vessel shall, however, in any case, 
be taken out or unladen therefrom, otherwise than is allowed by law, or 
according to the regulations hereinafter established. 

Sec. 4797. Whenever, by the prevalence of any contagious or epi- 
demic disease in or near the place by law established as the port of entry 
for any collection district, it becomes dangerous or inconvenient for the 
officers of the revenue employed therein to continue the discharge of 
their respective offices at such port, the Secretary of the Treasury, or, 
in his absence, the First Comptroller, may direct the removal of the 
officers of the revenue from such port to any other more convenient 
place, within, or as near as may be to. such collection district. And at 
such place such officers may exercise the same powers, and shall be liable 
to the same duties, according to existing circumstances, as in the port or 
district established by law. Public notice of any such removal shall be 
given as soon as may be. [See Sec. 1776.] 

Sec 4798. In case of the prevalence of a contagious or epidemic 
disease at the seat of government, the President may permit and direct 
the removal of any or all the public offices to such other place or places 
as he shall deem most safe and convenient for conducting the public 
business. [See Sec. 1776.] 

Sec 4799. Whenever, in the opinion of the Chief Justice, or, in 
case of his death or inability, of the Senior Associate Justice of the 



540 TEXT-BOOK OF HYGIENE. 

Supreme Court, a contagious or epidemic sickness shall render it haz- 
ardous to hold the next stated session of the court at the seat of govern- 
ment, the Chief or such Associate Justice may issue his order to the 
Marshal of the Supreme Court, directing him to adjourn the next session 
of the court to such other place as such justice deems convenient. The 
marshal shall thereupon adjourn the court, by making publication thereof 
in one or more public papers printed at the seat of government from the 
time he shall receive such order until the time by law prescribed for 
commencing the session. The several circuit and district judges shall, 
respectively, under the same circumstances, have the same power, by the 
same means, to direct adjournments of the several circuit and district 
courts to some convenient place within their districts respectively. [See 
Sec. 1176.] 

Sec. 4800. The judge of any district court, within whose district 
any contagious or epidemic disease shall at any time prevail, so as, in 
his opinion, to endanger the lives of persons confined in the prison of 
such district, in pursuance of any law of the United States, may direct 
the marshal to cause the persons so confined to be removed to the next 
adjacent prison where such disease does not prevail, there to be confined 
until they may safely be removed back to the place of their first confine- 
ment. Such removals shall be at the expense of the United States. 

Sec 4263. The master of any vessel employed in transporting pas- 
sengers between the United States and Europe is authorized to maintain 
good discipline and such habits of cleanliness among the passengers as 
will tend to the preservation and promotion of health ; and to that end 
he shall cause such regulations as he may adopt for this purpose to be 
posted up, before sailing, on board such vessel, in a place accessible to 
such passengers, and shall keep the same so posted up during the voyage. 
Such master shall cause the apartments occupied by such passengers to 
be kept at all times in a clean, healthy state; and the owners of every 
such vessel so employed are required to construct the decks and all parts 
of the apartments so that they can be thoroughly cleansed ; and also to 
provide a safe, convenient privy or water-closet for the exclusive use of 
every one hundred such passengers. The master shall also, when the 
weather is such that the passengers cannot be mustered on deck with 
their bedding, and at such other times as he may deem necessary, cause 
the deck occupied by such passengers to be cleansed with chloride of 
lime or some other equally efficient disinfecting agent. And for each 
neglect or violation of any of the provisions of this section the master 
and owner of any such vessel shall be severally liable to the United 
States in a penalty of fifty dollars, to be recovered in any circuit or 
district court within the jurisdiction of which such vessel may arrive 



QUARANTINE LAWS OF THE UNITED STATES. 541 

or from which she is about to depart, or at any place where the owner or 
master may be found. 

[Extract from Act of August 1, 1888.] 
Whenever any person shall trespass upon the grounds belonging to 
any quarantine reservation, . . . such person, trespassing, . . . 
shall, upon conviction thereof, pay a fine of not more than three hundred 
dollars, or be sentenced to imprisonment for a period of not more than 
thirty days, or shall be punished by both fine and imprisonment, at the 
discretion of the court. Aud it shall be the duty of the United States 
Attorney, in the district where the misdemeanor shall have been com- 
mitted, to take immediate cognizance of the offense, upon report made to 
him by any medical officer of the Marine-Hospital Service, or by any 
officer of the Customs Service, or by any State officer acting under 
authority of Section 5 of said act. 

[Act of March 27, 1890.] 

AN ACT to prevent the introduction of contagious diseases from one State to another 
and for the punishment of certain offenses. 

Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled. That whenever it shall 
be made to appear to the satisfaction of the President that cholera, 
yellow fever, small-pox. or plague exists in any State or Territory, or in 
the District of Columbia, and that there is danger of the spread of such 
disease into other States. Territories, or the District of Columbia, he is 
hereby authorized to cause the Secretary of the Treasury to promulgate 
such rules and regulations as in his judgment may be necessary to pre- 
vent the spread of such disease from one State or Territory into 
another, or from any State or Territory into the District of Columbia, or 
from the District of Columbia into any State or Territory, and to employ 
such inspectors and other persons as may be necessary to execute such 
regulations to prevent the spread of such disease. The said rules and 
regulations shall be prepared by the Supervising Surgeon-General of 
the Marine-Hospital Service, under the direction of the Secretary of the 
Treasury. And any person who shall willfully violate any rule or regu- 
lation so made and promulgated shall be deemed guilty of a misde- 
meanor, and upon conviction shall be punished by a fine of not more 
than five hundred dollars, or imprisonment for not more than two 
years, or both, in the discretion of the court. 

Sec. 2. That any officer, or person acting as an officer, or agent of 
the United States at any quarantine station, or other person employed 
to aid in preventing the spread of such disease, who shall willfully 
violate any of the quarantine laws of the United States, or any of the 



542 TEXT-BOOK OF HYGIENE. 

rules and regulations made and promulgated by the Secretary of the 
Treasury as provided for in Section 1 of this act, or any lawful order of 
his superior officer or officers, shall be deemed guilty of a misdemeanor, 
and upon conviction shall be punished by a fine of not more than three 
hundred dollars, or imprisonment for not more than one year, or both, in 
the discretion of the court. 

Sec. 3. That when any common carrier or officer, agent, or employe' 
of any common carrier shall willfully violate any of the quarantine laws 
of the United States, or the rules and regulations made and promul- 
gated as provided for in Section 1 of this act, such common carrier, 
officer, agent, or employe shall be deemed guilty of a misdemeanor, and 
shall, on conviction, be punished by a fine of not more than five hun- 
dred dollars, or imprisonment for not more than two years, or both, in 
the discretion of the court. 



QUESTIONS TO CHAPTER XXIII. 

Quarantine. 

What is meant b}~ quarantine? From what is the term derived? 
Has it now any definite limitation as to time ? To what is the term 
applied ? What are the two natural divisions of quarantine ? What are 
the principal quarantinable diseases ? What determines the length of 
quarantine for each of these ? Should tuberculosis be quarantinable ? 

What is meant by foreign quarantine ? What regulations are now 
to be observed at foreign ports b}^ vessels clearing for the United States? 
What officers have charge of this foreign quarantine ? 

What are some of the points considered in the bill of health? 
What are some of the requirements with regard to vessels and their 
cargoes ? Regarding passengers and crew ? What are the objects of the 
inspection card given to passengers ? 

What requirements are to be observed at sea ? What method is 
prescribed for the disinfection of vessels ? Of cargoes ? What can be 
said of the efficiency of the foregoing regulations ? 

What is meant by domestic quarantine ? What will govern the 
equipment of a maritime quarantine station? What are required at a 
fully -equipped station ? What is the method of construction of the most 
recent steam disinfecting chambers, and in what wa} T s are they superior 
to the earlier models ? What precautions are to be observed in operating 
them ? What is the principle of construction of the sulphur-furnaces 
now used at quarantine stations, and wherein are they superior to other 
methods of producing sulphurous-acid gas ? How is the gas to be con- 
veyed into the holds of vessels, etc. ? What apparatus is provided for 
using germicidal solutions ? Where barracks are necessary, how should 
they be arranged and equipped ? What facilities for bathing should be 
provided ? What is to be said of the water-supply ? 

What regulations are to be observed at ports of entry and on the 
frontier ? What points are covered by the inspection, and what vessels 
are exempt from inspection? What vessels are to be quarantined, and 
for how long ? What are the general requirements at quarantine ? What 
treatment must cholera-infected vessels undergo in quarantine ? What is 
the prescribed method of disinfection ? What routine is to be observed 
with passengers detained on account of cholera ? 

(543) 



544 QUESTIONS TO CHAPTER XXIII. 

How are the personal effects of passengers and crew and the cargo 
to be disinfected ? Under what conditions may traffic be allowed from 
ports infected with yellow fever? What inspection is required of State 
and local quarantines ? What regulations govern the Canadian and 
Mexican frontiers ? What are some of the points to be observed in the 
successful management of a quarantine station ? 

What are some of the special points in the disinfection of wooden 
vessels for yellow fever ? Is there any evidence that ballast may convey 
infection ? What is meant by " dipped ballast " ? How are the holds of 
wooden vessels to be disinfected ? What other treatment of yellow-fever 
vessels may be suggested ? 

What is the treatment required for cholera-infected vessels ? What 
special measures are to be taken against cholera ? Who has supreme 
command of a cholera camp, and how is it to be divided ? What are the 
regulations to be observed in the detention camp? In the hospital 
camp ? Why should infected dejecta and ejecta be disinfected immedi- 
ately upon discharge? 

How many national quarantine stations are there, and where are they 
located? Give a brief description of those in the Delaware Bay and 
River. What government vessel is used as a quarantine station ? 

What are some of the aids to national quarantine ? What inspection 
is required of all quarantines ? What is required of all State and local 
quarantines ? What are the instructions, both general and special, to the 
officers detailed to inspect State and local quarantines ? 

What is meant by inland quarantine ? By the sanitary cordon ? 
When and where has the latter been employed in the United States, and 
with what success ? What is a camp of probation ? What is the differ- 
ence between it and a camp of refuge ? How should a camp of probation 
be equipped, managed, and guarded ? What should be the daily routine 
of such a camp ? What regulations should be promulgated and enforced 
for such a camp ? Have these camps been efficacious in preventing the 
spread of disease ? 

What is the purpose of railroad quarantine, and how is it to be 
carried out ? How may it be facilitated by train-inspection service ? 
What rules are to be adopted for railway quarantine ? What action has 
been taken to prevent the introduction of small-pox, etc., from Canada? 
What are the regulations issued for the guidance of sanitary inspectors ? 
What provisions are there for the medical inspection of immigrants on 
board trains? 

What general principles govern interstate quarantine? What are 
the regulations covering it ? Which of these is the most important ? 



QUESTIONS TO CHAPTER XXIII. 545 

What special provisions are made respecting yellow fever ? What are 
the methods of disinfection prescribed, respectively, for cholera, yellow 
fever, small-pox, and typhus fever? 

What are the essential points of municipal quarantine ? What pre- 
cautions are to be taken to prevent the spread of small-pox, measles, 
diphtheria, and scarlet fever ? To what extent should domiciliary quar- 
antine be carried ? How long should it be maintained ? 

How may a diagnosis of diphtheria be made ? What means may be 
taken to prevent the spread of tuberculosis ? 

Give a synopsis of the quarantine laws of the United States. What 
is the maximum penalty for attempting to enter a port in evasion of 
them? What information of value to quarantine officers, etc., is 
furnished weekly? When and by whom may travel and traffic from 
infected ports and places be prohibited ? Who has supreme charge of the 
enforcement of the quarantine regulations ? In what department of the 
government does the supervision of quarantine belong ? 

35 



INDEX. 



Absolute and relative humidity, 6 
Actinomycosis, 376 
Adjustable school-desk, 211 
Adulterations in milk, 97 

of flour, 113 
"A. G. M." water-closet, 184 
Aids to quarantine, 497 
Air, 1 

currents and their influence upon 
health, 18 

examination of, 413 

tests for impurities in, 415 
Alcohol poisoning, 118 
Alcoholic beverages, 117 
Alimentary beverages, 117 
Alkaloidal beverages, 123 
Alum, as a purifier of muddy water, 63 

in bread, 437 
Ammonia in water, 78 

test for, 427 
Angus Smith's experiments on carbon 
dioxide and organic matter, 27 

modification of, 419 
Aniline poisoning, 236 
Animal diseases and ground-water, 142 
Annatto in milk, test for, 433 
Anthrax, 378 

Antiseptics and antisepsis, 387 
Arsenie, in wall-papers, 177 

poisoning, 241 
Ash in flour, 436 

in milk, test for, 433 
Asiatic cholera, 347 

Atmosphere, composition and physical 
conditions of, 2 

its influence upon health, 1 

its limit upward, 3 
Atmospheric pressure and health, 8 

Bacillus anthracis as a cause of diseased 

meat, 109 
Bacillus of anthrax, 378 

of glanders, 378 

of typhoid fever, 57, 67, 362 

tuberculosis, 532 
Bacteria in the atmosphere, 32 
Bacteriological examination of drinking- 
water, 81, 430 
Baker, H. B., on effects of low tempera- 
ture on health, 15 
Barometric pressure, 3 
Barracks, 252, 464 
Bathing, dangers of cold, 296 

rules for, 295 



Baths, and bathing, 293, 465 

public, 299 
Beer, 122 

Berlier's system, 156 
Bert's observations on diminished at- 
mospheric pressure, 10 
Beverages, alimentary, 117 

alkaloidal, 123 

containing alcohol, 117 
Birth- rate, 406 
Births, registration of, 404 
Black death, 326 

hole of Calcutta, 28 
Boccaccio on the plague, 326 
Bora, 19 

Boric acid in milk, tests for, 434 
Boudin on malarial fever from drinking- 
water, 64 
Bovine tuberculosis, 377 
Bowditch, H. L, on soil moisture and 

consumption, 141 
Brandy, 120 

"Brass-founders' ague," 235 
Bread, 112 

component parts of, 436 
Broad Street pump epidemic of cholera, 

68 
Bromine poisoning, 232 
Buchanan, Dr. G., on earth-closets, 154 

on soil moisture and consumption, 142 
Building material, 172 
Burial-grounds, supposed dangers of, 

308 
Bury ventilator, 175 
Butter, 101 

as food, 434 

component parts of, 434 

Cabiadis on the plague in Bagdad, 329 
Cable, G. W., on convict-lease system, 

281 
Caisson disease, 12 
Camp, detention, 492 

diseases, 254 

hospital, 493 

Perry, 506 

Waynesville detention, 509 
Camps, civilian, 258 

of probation, 505 
Carbon-bisulphide poisoning, 231 
Carbon dioxide in atmosphere, 2, 26 

poisoning, 230 
Carbon monoxide, in air, 29 

poisoning, 229 



(547) 



548 



INDEX. 



Caterham epidemic of typhoid fever, 65 
Census, the, 401 
Cerebro-spinal meningitis, 372 
Chamberland's filter, 73 
Chambers, J. W., on pollution of hy- 
drant-water, 70 
Chantemesse and Vidal on the bacillus 
typhoideus in drinking-water, 
67 
Cheese, 102 

Chemical composition of ground-air, 133 
Chlorides in water, 76 
Chlorine-gas poisoning, 228 
Chlorine in water, tests for, 424 
Chocolate, 124 
"Choke-damp," 230 
Cholera, 14, 68 

and drinking-water, 354 

and ground-water, 140 

Asiatica, 347, 520, 524 

bacillus, 352 

camp, regulations for, 491 

causation of, 353 

from infected water, 68 

prevention of, 356 

special quarantine measures against, 
488 

vessels, treatment of, 486 
Cider, 121 

Cisterns as storage reservoirs, 51 
Civilian camps, 258 
Classification of drinking-waters, 82 
Clothing, absorption of heat by, 301 

how to render non-inflammable, 304 

materials, 301 

of the soldier, 251 
Coal-gas, 30 
Coffee, 123 
Condiments, 114 
Connolly trap, 190 

Consumption, among school-children, 
218 

and soil moisture, 141 

prevention of, 533 
Contagion and infection, 319 
Contagious diseases and schools, 218 
Contagium animatum, 313 
Contamination of hydrant-water, 70 
Cooking, methods of, 115 
Cowles, Dr. E., experiments on heating 

hospitals, 200 
Creamometer, 100 
Cremation, 162, 310 

of sewage and garbage, 162 
Crematory at quarantine stations, 465 
Cucumber odor in drinking-water, 56 
Cultivation of bacteria, 316 
Cultures in suspected diphtheria, 532 
Cysticercus in meat, 106 

Da Costa, Dr. J. M., on irritable heart, 
288 



Daily allowance of water in American 

cities, 50 
Dead, disposal of, 307 
Death-rate and birth-rate 406 
Deaths, registration of, 405 
Decayed meat and fish as causes of dis- 
ease, 106 
"Dececo" closet, 185 
DeChaumont's rule regarding ground- 
water oscillations, 140 
Defective hearing among school-chil- 
dren, 216 
Defoe on the plague, 327 
Delabarre, F. A., on physical develop- 
ment, 288 
Dengue, 369 
Deodorizers, 388 

Diarrhoea and dysentery in armies, 254 
Diarrhceal diseases, 14 
Dickson on the plague in India, 329 
Digestive derangements among school- 
children, 217 
Diphtheria, 322, 368, 529 
• diagnosis of, 531 

Diseases caused by high temperature, 
14 

from impure water, 62 

from infected and spoiled meat, 105 

from infected milk, 98 

from soil impurities, 139 

of animals communicable to man, 376 

of school-children, 213 

on shipboard, 271 

registration of, 405 
Disinfectants and disinfection, 387 
Disinfection, methods of, 393 

by germicidal solutions, 463 

for cholera, 524 

for small-pox, 525 

for typhus fever, 526 

for yellow fever, 525 

of wooden vessels, 479 
Distilled water, 58 
Domestic quarantine, 458 
Domiciliary quarantine, 527 
Drainage of wet soils, 143 
Drinking-water, examination of, 81 

sources of, 51 

standards of purity of, 59 
Drowned persons, restoration of, 296 
Duration of infection, 321 
Dwellings, and overcrowding, 165 

heating and ventilation of, 174 

materials of which to be built, 172 
Dysentery, 14 

Earth-closets, 153 

Eberth's bacillus as a cause of typhoid 

fever, 67 
Eggs as food, 111 
Elephantiasis, 14 
Electric light and its dangers, 179 



INDEX. 



549 



Emigrant ships, sanitary and medical 

service on board, 273 
Emmerich on the innocuousness of im- 
pure water, 65 
Entombment, 309 
Epidemic diseases, 320, 372 

due to defective ventilation, 29 

history of, 325 
Erismann on Liernur's system, 155 
Examination of air, water, and food, 413 
Exercise and training, 285 

physiological effects of, 285 

Fats in milk, test for, 433 
Fever, malarial, 14, 63, 64, 255 

mountain, 53 

relapsing, 360 

scarlet, 99, 322, 367, 529 

splenic, 314 

typhoid, 65, 67, 141, 256, 322, 361, 409 

typhus, 256, 363, 526 

yellow, 14, 135, 364, 485, 503, 509, 512, 
523, 525 
Filtration of water, 73 
"Fire-damp," 30, 230 
Flour and bread, 436 

component parts of, 436 

tests for impurities in, 437 
Flushing cistern for water-closets, 187 
Fodor on the production of carbon di- 
oxide, 27 
Fohn, 19 
Folsom, C. F., on typhoid fever from 

infected water, 67 
Food, examination of, 431 

necessary to health, 87 

of the soldier, 250 
Foods, classification, of, 95 

cooking of, 115 

of animal origin, 95 

of vegetable origin, 112 
Foreign quarantine, 443 
Forwood, Dr. W. S., on hydrochloric- 
acid fumes, 228 
Freire on yellow-fever germ in soil, 135 
Fresh-air inlet, 191 
Fruits and nuts, 114 

Gardner, James T., on Rochdale sys- 
tem, 151 
Gas poisoning, 29 
Germ theory, 313 

Germicidal solutions, disinfection by, 463 
Gihon, Dr. A. L., on naval hygiene, 261 

on syphilis in the United States, 342 
Gin, 121 
Glanders, 378 
Green vegetables, 114 
Ground-air, 132 
Ground-water, 137 

and cholera, 140 

and typhoid fever, 141 



Habitations, 165 
Habits of the sailor, 261 
Haemic diseases, 14 

Hammond's experiment on organic mat- 
ter in the air, 28 
Hardness of water, 60 

tests for, 428 
Harmattan, 19 

Heart disease and altitude, 11 
Heating and ventilation of dwellings, 

174 
Hecker on the plague, 326 
Hold, ship's, disinfection of, 483 
Hopper-closets, 182 

Hospital, administration and manage- 
ment, 203 

records, 205 
Hospitals, construction of, 195, 463 

management of, 203 

ventilation and heating of, 199 
House, building material of, 172 

interior arrangements of, 174 

sanitary arrangements, supervision of, 
191 

water-supply of, 180 
House-drainage, 180 
Howard, John, on hospital construction, 

199 
Humidity, and health, 18 

of the atmosphere, 5 
Hydrophobia, 377 
Hygiene, industrial, 223 

marine, 261 

military and camp, 249 

prison, 279 

school, 207 

Illuminating gas, dangers of, 178 
Impurities in water, 59 

signification of, 80 

tests for, 74 
Increased atmospheric pressure, 12 
Incubation of infectious diseases, table 
of, 321 

report of, to the London Clinical 
Society, 321 
Industrial hygiene, 223 
Infants, mortality among, 408 
Influence of barometric pressure upon 

results of operations, 12 
Influenza, 15, 322, 371 
Ingrafting, 335 
Inland quarantine, 501 
Inoculation of small-pox, 335 
Interment, 307 

in war, 310 
Interstate quarantine, 521 

regulations governing, 522 
Iodine poisoning, 232 

Jenner, Edward, and vaccination, 338 
Jesty, Benjamin, 338 



550 



INDEX. 



Johns Hopkins Hospital, 196 
Jones, Dr. Joseph, on syphilis among 
the mound-builders, 374 

Kefyr, 122 

Kober, G. M., on mountain fever, 53 
Koch, R., on the cholera spirillum in 
drinking-water, 69 

Kumys, 122 

Lactometer, 100 

Lactoscope, 100 

Lakes and ponds as sources of drinking- 
water, 55 

Lambrecht's polymeter, 8 

Latrines, 465 

Lead poisoning, 233 

Legumes, 113 

Liernur's pneumatic system, 155 

Lighting of dwellings, 177 

Lortet's observations on diminished at- 
mospheric pressure, 8 

Low temperature as a cause of respira- 
tory diseases, 15 

Malarial fevers, 14 

in armies, 255 
Marine hygiene, 261 
Maritime quarantine, 458 

administration of, 466 
Marriages, registration of, 404 
Marsh-water and malaria, 63 
Marshall, John, on cholera from infected 

water, 68 
Mate, 125 

McClellan's trap, 188 
McSherry, R., on sisuatera, 108 
Measles, 322, 367, 529 
Meat, 103 

extracts and essences, 105 
Mercurial poisoning, 234 
Metabolism during muscular exercise, 

94 
Methods of cooking, 115 

of sewage removal, 148 
Michigan method of restoring the ap- 
parently drowned, 297 
Midden privies, 150 
Military and camp hygiene, 249 
Milk, as food, 95, 431 

adulteration of, 432 

component parts of, 432 

sickness, 100 

tyrotoxicon in, 101 
Mineral poisons in water, 79 

tests for, 429 
Mistral, 18 
Montagu, Lady M. W., on inoculation, 

335 
Montgomery quarantine conference, 515 
Moore, J. W., on seasonal prevalence 
of pneumonia, 17 



Morin, on fresh air required in occupied 

apartments, 40 
Mortality among infants, 408 

in prisons, 281 
Motion of the atmosphere, 7 
Mountain fever, 53 

sickness, 10 
Municipal quarantine, 526 
Mumps, 322 
Myopia of school-children, 213 

National quarantines, 494 
aids to, 497 

stations, regulations for, 466 
Naval hygiene, 261 

rations, 268 
Neirnsee, J. R., on ventilating hospital 

wards, 200 
Nervous disorders among school -chil- 
dren, 217 
Nichols, A. H., on pollution of drinking- 
water, 56 
Nitrates and nitrites in water, 77 

tests for, 425, 426 
Norther, 19 

Occupation neuroses, 245 
Occupations, hygiene of, 223 
Oleomargarine, 102, 434 
Organic matter in water, 75 
Organisms in small-pox, 334 
Oriental plague, 325 
Over Darwen epidemic of drinking- 
water, 66 
Overexertion, 288 

Oxygen and C0 2 in ground-air, 134 
Oxygen in atmospheric air, 3 
Ozone in the atmosphere, 7 

Pan-closets, 181 
Passengers on shipboard, 264 
protection of, 273 

report on, to American Public Health 
Association, 274 
Pathogenic organisms in ground-air, 134 
Pavilion hospitals, 18 
Pebrine, 314 

Pengra, C.P., on bacteria in drinking- 
water, 57 
Pepper, William, on consumption and 

soil moisture, 142 
Perlsucht, 377 

Peroxide of hydrogen in the atmos- 
phere, 7 
Petroleum vapor as a poison, 233 
Pettenkofer, on carbon dioxide in air, 
420 
on ground-air, 133 
on ground-water and cholera, 355 
Phosphates in water, tests for, 430 
Phosphorus necrosis, 242 
Phthisis in armies, 256 



INDEX. 



551 



Physical development, table on, 289 

training, 286 
Physiological action of alcohol, 117 
Plague, 325 
Plunger-closets, 182 
Plymouth epidemic of typhoid fever, 67 
Pneumonia and cold weather, 16 
Poisonous dust, 237 

gases and vapors, 227 
Power, W. H., on scarlet fever from 

milk, 99 
Preventive inoculation, 315 
Prison hygiene, 279 

punishments, 282 
Privies, deodorization of contents of, 
149 

removal of contents of, 149 

ventilation of, 149 
Privy-vaults, construction of, 148 

pits, 150 

system, 148 

wells, 150 
Procopius on the plague, 325 
Prudden on typhoid bacilli in drinking- 
water, 57 
Ptomaines in meat, 107 
Public baths, 299 
Purification of drinking-water, 72 
Purulent conjunctivitis, 256 

Quarantinable diseases, 442 
Quarantine, 441 
aids, 497 

conference at Montgomery, 515 
contrivances, 459 
danger from flies in, 494 
domestic 458 
domiciliary,. 527 
foreign, 443 

regulations, efficiency of, 456 
inland, 501 
interstate, 521 
laws of United States, 534 
municipal, 526 
plant, 459 
railroad, 512 
regulations governing, 466 

to be observed at foreign ports and 
at sea, 443 
service, national, 494 
stations, management of, 477 

maritime, 458 

on Delaware Bay and River, 495 
Quarantines, national inspection of all, 
498 
instructions for inspecting officers, 499 
Questions to chapter i, 45-48 
to chapter ii, 84-86 
to chapter iii, 126-129 
to chapter iv, 145, 146 
to chapter v, 163, 164 
to chapter vi, 193, 194 



Questions to chapter vii, 206 
to chapter viii, 220, 221 
to chapter ix, 247, 248 
to chapter x, 260 
to chapter xi, 278 
to chapter xii, 284 
to chapter xiii, 291 
to chapter xiv, 300 
to chapter xv, 305 
to chapter xvi, 312 
to chapter xvii, 317 
to chapter xviii, 323 
to chapter xix, 380-385 
to chapter xx, 399, 400 
to chapter xxi, 411, 412 
to chapter xxii, 439, 440 
to chapter xxiii, 543-545 

Rabies, 377 

Rag-sorters' disease, 240 
Railroad inspection against small-pox, 
516 
against yellow fever, 514 
medical inspection of immigrants 

against cholera, 520 
quarantine, 512 
Rain-water, 52 
Registration of births, 404 
of deaths, 405 
of diseases, 405 
of marriages, 404 
Relapsing fever, 360 
Rennie on the plague, 329 
Restoration of apparently drowned per- 
sons, 296 
River-water, 52 
Rochdale system, 151 
Roy, A., on carbon-dioxide poisoning, 

230 
Rubeola, 322 
Rum, 121 

Sailor-life, 261 
Sanitary cordon, 501 
Sausage poisoning, 107 
Scarlet fever, 322, 367, 529 

from milk, 99 
Schlagintweit's observations on mount- 
ain sickness, 9 
Schone system, 156 
School-furniture, 210 

-house construction, 207 

-hygiene, 207 

-life, diseases of, 213 
Scurvy in armies, 256 
Sea-bathing, 294 

Season and mortality from various dis- 
eases, 20 
Seaton and Buchanan on protective 

power of vaccination, 341 
Self- purification of flowing water, 54 
Separate system, 156 



552 



INDEX. 



Sewage, and sewerage, 147 

farms, 161 

final disposal of, 161 

irrigation at Pullman, 161 

removal, methods of, 148 
Sewer-air, 30 
Sheep pock, 376 
Ship sanitation, 264 
Siegfried, Surg. C. A., on naval rations. 

271 
Simoon, 19 
Sirocco, 19 

Site for dwellings, 167 
Small-pox, 331, 516, 525 

limiting the spread of, conference in 
Chicago, 346 
Smart, C, on mountain fever, 53 

on pollution of cistern-water, 51 
Soap test for hardness in water, 60 
Soil, atmosphere of, 132 

character of, for building sites, 168 

drainage, 143 

its physical and chemical characters, 
131 

moisture and health, 167 

pipe, 189 

water of the, 137 
Solids in water, 75 

of milk, tests for, 433 
Sources of drinking-water, 51 
Spinal curvature in school-children, 217 
Spirillum of relapsing fever, 361 
Splenic fever, 314 
Spongilla fluviatilis, 56 
Spring-water, 57 
Standards of purity of drinking-water, 

59 
Statistics, vital, 401 
Steam disinfecting chambers, 460 
Sternberg, G-. M., on destruction of 
pathogenic germs by boiling 
water, 72 

on yellow-fever germs of Freire, 135, 
365 
Storage of water, 51, 71 
Study-hours for pupils, 212 
Suicide and season, 26 
Sulphur-furnace, 462 
Sun-stroke and humidity, 13 
Supervision of sanitary arrangements, 

191 
Sweating sickness, 330 
Swell-head, 376 
Swill-milk, 99 
Syphilis, 373 

Table of constituents of animal foods, 
90 

of constituents of vegetable foods, 91 
Tea, 124 
Temperature and health, 13 

of the air, 5 



Temperature of fire-rooms of ships, 268 
Tents and huts, 253 
Tests for atmospheric impurities, 33 
415 

for impurities in drinking-water, 74, 
423 
in food, 431 
Texan northers, 19 

Thorne on typhoid fever from drinking- 
water, 65 
Tobacco, 125 

Toilet's system of barracks, 252 
Tracy, Dr. R. S., on infecundity of 

tobacco-workers, 239 
Training, physical, 286 
Traps, 187 
Trembles, the, 100 
Trichina spiralis in meat, 105 
Tuberculosis, 532 
Tuberculous meat, 110 
Turpentine vapor, effects of, 232 
Typhoid fever, 361, 322 

and ground-water, 141 

causation of, 362 

from drinking-water, 65 

in armies, 256 
Typhus fever, 363 

in armies, 256 
Tyrotoxicon in milk, 101 

Vaccination, 337 

and syphilis, 343 

mode of performing the operation, 
341 
Valve-closets, 182 

Vaughan, V. C, on the bacillus ty- 
phoideus in drinking-water, 68 

on poisonous cheese, 103 

on tyrotoxicon as a cause of cholera 
infantum, 101 
Vaughan's daily ration, 89 
Vegetables, green, 114 
Venereal diseases in armies, 257 
Ventilation, 38 

and heating of hospitals, 199 

of prisons, 282 

of ships, 266 
Vessels, cholera, treatment of, 486 

wooden, disinfection of, 479 

yellow-fever, treatment of, 485 
Vital statistics, 401 
Voit's standard diet-tables, 89 

Waring system at Memphis, 157 

examination of, 423 
Water, 49 

hardness, of, 60 
tests for, 428 

impurities in, 59 

diseases due to, 62 

required by human beings, 49 

storage and purification of, 71 



INDEX. 



553 



"Water-supply, at quarantine stations, 465 

in dwellings, 180 

tests for impurities in, 74, 423 
Water-carriage system of sewage re- 
moval, 156 
Water-closets, 181 
Well-water, 57 
Whisky, 120 
Wines, 121 
Wolpert's air-tester, 34 



Wolpert's air-tester, modification of, 418 
Wool-sorters' disease, 240 
Wyman's case-record, 205 

Yellow fever, 14, 364 
causation of, 14, 365 
cordon in Texas, 503 
epidemic in Brunswick, Ga., 509 

in Florida, 512 
vessels, treatment of, 485 




iiiiiiiiiiiiiiiiiiiiiiii^ 



August, 1894 



Catalogue of the Publications gj 

of 

THE F. A. DAVIS CO., 

Medical Publishers and Booksellers, 
1914 and 1916 CHERRY STREET, 

PTlIItADBItPHlA, PA. 



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nmnnmiilllllllll 




Catalogue of the Publications 



ot 



THE F. h. DAVIS CO., 

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PHlIiRDEIiPHlflL, u. s. R. 



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* BALLIN — Personal Hygiene. 

By Mrs. Ada S. Ballin, Editor of " Baby ; the Mothers' Magazine." Crown 
Octavo. About 250 pages. Cloth. 

Price, in United States and Canada, Sl.OO, net; Great Britain, 4s.; 
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BASHORE— Improved Clinical Chart. 

For the Separate Plotting of Temperature, Pulse, and Respiration. But one 
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BOENNING— Text=Book on Practical Anatomy. 

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BOUCHARD— Autointoxication. 

Being a series of lectures on Intestinal and Urinary Pathology. By Prof. Ch. 
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BURET — Syphilis in Ancient and Prehistoric Times. 

With a chapter on the Rational Treatment of Syphilis in the Nineteenth Cen- 
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CAPP— The Daughter. 

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CATHELL — Book on the Physician Himself. 

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CLEVENGER— Spinal Concussion. 

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COLTriAN— The Chinese: Their Present and Future. 

Medical, Political, and Social. By Robert Coltman, Jr., M.D., Surgeon in 
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DAVIS — Diseases of the Lungs, Heart, and Kidneys. 

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(2) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



DAVIS— Consumption : How to Prevent it and How to 
Live with it. 

Its Nature, Causes, Prevention, and the Mode of Life, Climate, Exercise, Food, 
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Price, in United States and Canada, 75 cts., net ; Great Britain, 4s. ; 
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DEMARQUAY— On Oxygen. 

A Practical Investigation of the Clinical and Therapeutic Value of the Gases 
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ability of Oxygen, Nitrogen, Hydrogen, and Nitrogen Monoxide. By J. N. Demar- 
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EDINQER— Structure of the Central Nervous System. 

For Physicians and Students. By Dr. Ludwig Edinger, Frankfort-on-the- 
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EISENBERG— Bacteriological Diagnosis. 

Tabular Aids for use in Practical Work. By James Eisenberg, Ph.D., M.D., 

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FIREBAUGH— The Physician's Wife. 

And the Things that Pertain to Her Life. By Ellen M. Firebaugh. 
Gracefully written, full of genuine humor, and true to nature, this little volume is a 
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GANT and ALLINGHAM— Diseases of Rectum and Anus. 

By S. G. Gant, M.D., Professor of Rectal and Anal Surgery in the University 
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(3) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



Training School and Hospital for Nurses, etc. ; and H. W. AliLlNGHAM, M.D. 
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GOODELL — Lessons in Gynaecology. 

By William Goodell, A.M., M.D., etc., Professor of Clinical Gynaecology in 
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GRANDIN and JARI1AN— Obstetric Surgery. 

By Egbert H. Grandin, M.D., Obstetric Surgeon to the New York Maternity 
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GUERNSEY— Plain Talks on Avoided Subjects. 

By Henry N. Guernsey, M.D., formerly Professor of Materia Medica and 
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Book I. Introductory. II. The Infant. III. Childhood. IV. Adolescence of the 

Male. V. Adolescence of the Female. VI. Marriage: The Husband. VII. The 
Wife. VIII. Husband and Wife. IX. To the Unfortunate. X. Origin of the Sex. 
16mo. Bound in Extra Cloth. 

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HARE— Epilepsy : Its Pathology and Treatment. 

By Hobart Amory Hare, M.D., B.Sc, Professor of Materia Medica and 
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Price, in United States and Canada, $1.25, net ; Great Britain, 6s. 6d. ; 
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HARE— Fever: Its Pathology and Treatment. 

Containing Directions and the Latest Information Concerning the Use of the 
So-called Antipyretics in Fever and Pain. By Hobart Amory Hare, M.D., B.Sc. 
Illustrated with more than 25 new plates of tracings of various fever cases, showing 
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Price, in United States and Canada, $1.25, net; Great Britain, 6s. 6d. ; 

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(4) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



HUIDEKOPER— Age of the Domestic Animals. 

Being a Complete Treatise on the Dentition of the Horse, Ox, Sheep, Hog, and 
Dog, and on the various other means of determining the age of these animals. By 
Rush Shippen Huidekoper, M.D., Veterinarian (Alfort, France) ; Professor of 
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International System of Electrotherapeutics. 

For Students, General Practitioners, and Specialists. Chief Editor, Horatio 
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IVINS — Diseases of the Nose and Throat. 

A Text-Book for Students and Practitioners. By Horace F. Ivins, M.D., 
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* JOAL — On Respiration in Singing. 

For Specialists, Singers, Teachers, Public Speakers, etc. By Dr. Joal (Mont 
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KEATING— Record=Book of Medical Examinations for Life= 
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Designed by John M. Keating, M.D. This record-book is small, but com- 
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(5) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



KEATING and EDWARDS— Diseases of the Heart and 
Circulation in Infancy and Adolescence. 

With an Appendix entitled "Clinical Studies on the Pulse in Childhood." By 
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delphia. Illustrated by Photographs and Wood-Engravings. About 225 pages. 8vo. 
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Price, in United States and Canada, $1.50, net ; Great Britain, 8s. 6d. ; 
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KRAFFT-EBING— A Text=Book on Insanity. 

• For the Use of Students and Practitioners. By Dr. R. von Krafft-Ebing. 
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LIEBIG and ROHE— Electricity in Medicine and Surgery. 

By G. A. Liebig, Jr., Ph.D., Assistant in Electricity, Johns Hopkins Uni- 
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Price, in United States and Canada, $2.00, net; Great Britain, lis. 6d. ; 
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fl ANTON — A Syllabus of Lectures on Human Embryology. 

An Introduction to the Study of Obstetrics and Gynaecology, with a Glossary 
of Embryological Terms. By Walter Porter Manton, M.D., Lecturer on Ob- 
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Price, in United States and Canada, SI. 25, net ; Great Britain, 6s. 6d. ; 
France, 7 fr. 75. 

MASSEY — Electricity in the Diseases of Women. 

With Special Reference to the Application of Strong Currents. By G. Betton 
Massey, M.D., Late Electro-Therapeutist to the Philadelphia Orthopaedic Hospital 
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With New and Original Wood-Engravings. Extra Cloth. 240 pages. 12mo. 

Price, in United States and Canada, SI. 50, net; Great Britain, 8s. 6d. ; 
France, 9 fr. 35. 

fledical Bulletin Visiting List, or Physicians' Call Record. 

Arranged upon an Original and Convenient Monthly and Weekly Plan for the 
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(6) 



Medical Publications of the F. A. Davis Co , Philadelphia. 



niCHENER— Hand=Book of Eclampsia. 

Or, Notes and Cases of Puerperal Convulsions. By E. Michexer, M.D. ; 
J. H. Stubbs, M.D. ; R. B. Ewing, M.D. ; B. Thompson, M.D. ; S. Stebbins, 
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riONTGOMERY— Practical Gynaecology. 

By E. E. Montgomery, A.M., M.D., Professor of Clinical Gynaecology in the 
Jefferson Medical College, Philadelphia, etc., etc. In one Royal Octavo volume. 
Thoroughly Illustrated. In Preparation. 

*MOORE— meteorology. 

By J. W. Moore, B.A., M.Ch., University of Dublin ; Fellow and Registrar of 
the Royal College of Physicians of Ireland, etc. Part I. Physical Properties of the 
Atmosphere. Part II. A Complete History of the United States Weather Bureau 
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Price, post-paid, in United States and Canada, S2.00, net ; Great Britain, 
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*MYGIND— Deaf-Mutism. 

By Holger Mygind, M.D., of Copenhagen. The only authorized English 

Edition. Edited by R. Norris Wolfenden, M.D.Cantab., of London. Comprising 

Introduction, Etiology and Pathogenesis, Morbid Anatomy, Symptoms and Sequelae, 

Diagnosis, Prognosis, and Treatment. Crown Octavo. About 300 pages. Cloth. 

Price, post-paid, in United States and Canada, $2.00, net; Great 

Britain, 8s. ; France, 9 fr. 50. 

NISSEN — A Manual of Instruction for Giving Swedish 
flovement and Massage Treatment. 

By Prof. Hartvig Nissen, late Instructor in Physical Culture and Gym- 
nastics at the Johns Hopkins University, Baltimore, Md., etc. With 29 Original 
Wood-Engravings. 12mo. 128 pages. Cloth. 

Price, in United States and Canada, SI .00, net ; Great Britain, 6s. ; 
France, 6 fr. 20. 

Physicians' All~Requisite Time« and Labor- Saving 
Account«Book. 

Being a Ledger and Account-Book for Physicians' Use, meeting all the Re- 
quirements of the Law and Courts. Designed by William A. Seibert. M.D., of 
Easton, Pa. There is no exaggeration in stating that this Account-Book and Ledger 
reduces the labor of keeping physicians' accounts more than one-half, and at the 
same time secures the greatest degree of accuracy. 

Prices : No. 1, 300 pages for 900 Accounts per Year, size 10 x 12, bound 
in %-Russia, Raised Back-Bands, Cloth Sides, in United States and 
Canada, S5.00, net ; Great Britain, 28s. ; France, 30 fr. 30. 
No. 2, 600 pages for 1800 Accounts per Year, size 10 x 12, bound in 
%-Russia, Raised Back-Bands, Cloth Sides, in United States and 
Canada, S8.00 ; Great Britain, 42s. ; France, 49 fr. 40. 
Send for descriptive circular showing the plan of the book. 

(7) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



Physicians' Interpreter. 

Ill Four Languages, English. French, German, and Italian. Specially arranged 
for diagnosis by M. VON V. The plan of the book is a systematic arrangement of 
questions upon the various branches of Practical Medicine, and each question is so 
worded that the only answer required of the patient is merely Yes or >v"o. Bound in 
full Russia Leather, for carrying in the pocket. Size, 5x2% inches. 206 pages. 
Price, in United States and Canada, Sl.OO, net ; Great Britain, 6s. ; 
France, 6 fr. 30. 

PURDY— Diabetes. 

Its Cause. Symptoms, and Treatment. By Chas. W. Purdy, M.D., Honorary 
Fellow of the Royal College of Physicians and Surgeons of Kingston ; Author of 
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(8) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



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ROHE— Text- Book of Hygiene. 

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* SCHUSTER— When is flarriage Permissible after Syphilis? 

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(9) 



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SHOEMAKER— Heredity, Health, and Personal Beauty. 

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(10) 



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STEWART— Obstetric Synopsis. 

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STRAUB— Symptom Register and Case Record. 

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transactions of the fleetings of the British Laryngological 
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ULTZriANN— The Neuroses of the Genitourinary System 
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(11) 



Medical Publications of the F. A. Davis Co., Philadelphia. 



VOUGHT — Chapter on Cholera for Lay Readers. 

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WITHERSTINE— International Pocket Medical Formulary. 

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YOUNG — Synopsis of Human Anatomy. 

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(12) 



Medical Publications of The F. A. Davis Co., Philadelphia. 



ADAMS— History of the Life of D. Hayes Agnew, n.D., LL.D. 

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KRAFFT=EBINQ— Psychopathia Sexualis. 

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SAJOUS— Lectures on the Diseases of the Nose and Throat. 

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SCHRENCK=NOTZING— Suggestive Therapeutics in Psy= 
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